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Dane County For Office Use Only—Revised 10.16.2017 <br /> Erosion Control Permit Permit Number <br /> Simplified Application <br /> (Application must be made in-person. Received &Approved By. Date: <br /> Incomplete applications will not be accepted.) <br /> This form may only be used for the following projects: <br /> 1. Land disturbing activities meeting the criteria of DCCO s. 14.50(2) <br /> 2. Land disturbing activities occurring in the Shoreland Zone meeting the criteria of DCCO s. 11.05(2)(b)or(d) <br /> Please see Dane County Code of Ordinances for the complete list of qualifying criteria. <br /> Project Name:House Applicant Information (Individual making in-person application) <br /> Landowner Name(s):Anniversary Dream Estates, LLC ApplicantName:SCott & Elizabeth Herrling <br /> Landowner Address: 3987 Barlow Road Applicant Address: <br /> Landowner Phone. (6 0 8 ) 798 -3151 Applicant Phone: <br /> Landowner E-mail:herrllnq@Chorus . net Applicant E-mail: <br /> Type of Permit: ^rte ,ti_ <br /> 17Erosion Control (EC) l,A � `��41'4 .) Shoreland Erosion Control (SE) <br /> (check only one) <br /> Municipality:Town of Vermont - Section: 6 Quarter: NE Parcel Number: 0706 - 111- 8001-3 <br /> Fee Calculation i L ;i `'0446'" <br /> pyx <br /> . l t 15 000 ` <br /> Total Disturbed Area....... , <br /> Total New Impervious........ .................. 3 , 6 3 7 ft` <br /> (includes gravel) R Base Fee =$ 100 . 00 <br /> Late Filing Fee:Permit fee shall be doubled where work has begun <br /> before a permit has been obtained(s. 11 50(7) or 14.55(2)(b)). Total Fee=$ 100 . 00 <br /> Notes: <br /> 1. 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 /> 2. By submitting this application, permittee and landowner permit Dane County staff to enter project property for inspection and/or <br /> curative action (s. 11.05(5)(a)3 or 14.49(4)(c)). <br /> I am the landowner or have been authorized via the included authorization form to act on behalf of the owner. I understand <br /> by signing and submitting this application 1 am bound by the requirements of the County's erosion control ordinance and <br /> accept responsibility for implementation of the plan included with this application. <br /> Applicant Signature: L 2z 7i44'2L Date: n4/o /20 <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 /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />