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Dane County <br /> � � � �� <, <br /> Erosion Control & Stormwater 9, T ,yr3 <br /> k <br /> Management Permit Application Datio q ,,, ! „. t §t <br /> p LY <br /> (Incomplete applications will not be accepted) „kingl >,.a. `....'i s4` 11"i6.. e ., ,.,N; <br /> Project Name:Albert Driveway & Garage Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Michael Albert Applicant Name: same <br /> Landowner Address: 3963 Ryan Rd Applicant Address: <br /> Blue Mounds, WI 53517 <br /> Landowner Phone: 608.767.2072 Applicant Phone: <br /> Landowner E-mail: amalbert(p7tds.net Applicant E-mail: <br /> Name and company of engineer/consultant who prepared the plans: /t-YSd.,<{l 5 , L IG <br /> Type of Permit: Erosion Control Only " Erosion Control&Stormwater Management n Stormwater Management Only <br /> (check only one) (EC) (ES) (SM) <br /> Redevelopment Shoreland.Erosion Control Only Shoreland Erosion Control& <br /> (RD) (SE)' Stormwater Management(SS) <br /> Municipality:Town of Vermont Section: ;.19' =NE %"ofthe..-NE :'1, Parcel#: 0706-191-8020-4 <br /> Fee Calculation(all projects must include disturbed'area and new,impervious,even"•if notYsubject to fee as noted by brackets) <br /> Total Disturbed Area...[EC,ES,RD,SE,SS] 4,500` ft2x$0.0040/ft2 =$ 18.00 <br /> Total New Impervious...[ES,SM,RD,SS]..... • , ' ' ft2x$0.0050/ft2=$ <br /> (includes gravel) <br /> Total Redevelopment Impervious...[RD].. ....:. ft2x$0.0025/ft2 = $ <br /> (includes gravel) <br /> Base Fee: EC, ES, SM, or RD($200); SE or SS with new,or replacement structure($400); Base Fee=$ 400.00 <br /> SE or SS without new or replacement structure($200); or SE permit with P.E.waiver under <br /> DCCO 11.05(2)(b)($50)[subtract PRL fee($50)if application includes PRL and receipt] Total Fee=$ 418.00 <br /> Notes: <br /> 1. Be sure to clearly indicate the extent(limits)and size(ft2)of all disturbed and impervious areas on your plan <br /> 2.All requirements included in this application correspond to the requirements set forth in chapters 11 and/or 14 of the Dane <br /> County Code of Ordinances <br /> 3. By submitting this application, permittee and landowner permit Dane County staff to enter project property for inspection and/or <br /> curative action(s. 14.49(4)c or 11.05(5)(a)3 DC Code of Ordinances) <br /> Applicant Signature: Date: <br /> If the person applying(submitting the application in-person, at the counter)is not the landowner, a notarized statement <br /> authorizing the applicant to act as the landowner's agent must be attached <br /> Permit Received by: Date: <br /> Permit Reviewed by: Date: <br /> This application must be submitted in person M-F, 8 A.M. — 4 P.M., <br /> with two copies of all permit materials to: <br /> Dane County Land Conservation, 1 Fen Oak Ct, Room 208, Madison, WI <br />