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Dane County For Office Use Only—Revised 10.16.2017 <br /> Erosion Control Permit Permit Number <br /> Application Application Received By: Date: <br /> Application must be made in-person. Application Approved By: Date: <br /> Incomplete applications will not be accepted. <br /> Associated Permits: <br /> Project Name: ;ti, J�)rrrO,C ;r ?+i rr ty;�;w <br /> 2 <br /> Applicant Information(Individual making in-person application) <br /> •i ?-r'� A':• �j'1.-' i_.1_`: .:''.' '+..'�- 1)ry''?F f"' r!I<;? , f o 1.4 <br /> Landowner Name(s): _';' •f, ':'$f ?;. . Applicant Name: )./, d; + •'' a <br /> Landowner Address: (/2,LI• i /+ t 1 }: > >•;,,y <br /> _ . .. . i� _ a e� Applicant Address: • �:; ��=fid 3- �i: ;.x., !',,. ,,�i <br /> • <br /> Landowner Phone: , r •- Applicant Phone: i' 9ci (..-O ; c'.,"?‘-- <br /> , <br /> :-?� <br /> Landowner E-mail: ±.r` y�:'.t\! r G• s9 k,,•. 0.,)y-E:" 1j'� <br /> �: rr`. � :r. <•_ Applicant E-mail: <br /> Name and company of engineer/consultant who prepared the plans: <br /> Type of Permit: Erosion Control " • Sh tOji .Erosion Control <br /> (check only one) (EC) ,.'- ';fi�;(S }:. <br /> Municipality: I Chi. :. 5 ' � . � Quarter: • Parcel#: JZ0/06 0—C9 -• �11 v—� <br /> Fee Calculation <br /> Total Disturbed Area x$0.006/ftp=$ <br /> Total New Impervious Area '• ``x:. ft2 <br /> (includes gravel) <br /> Total Redevelopment Impervious Area ' .t ft2 <br /> (includes gravel) . <br /> Base Fee: Erosion Control(EC) $200 Base Fee=$ <br /> Shoreland Erosion Control(SE)$400 <br /> Shoreland Erosion Control(SE)meeting criteria s.11.05(2)(c)$200 Total Fee=$ 0 . 0 0 <br /> Late Filing Fee:Permit fee shall be doubled where work has begun before a permit <br /> has been obtained(s. 11.50(7)or 14.55(2)(b)). <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 by <br /> signing and submitting this application I am bound by the requirements of the County's erosion control ordinance and accept <br /> I,.: responsibility for implementation of the plan.included with this application. <br /> Applicant Signature: �;��, .� - ` Date: '- <br /> This application must be submitted in person (M-F, 8 A.M. —4 P.M.) to: <br /> Water Resource Engineering Division, 5201 Fen Oak Drive, Room 208, Madison, WI 53718 <br />