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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: Proposed Garage Applicant Information(Individual making in-person application) <br /> Landowner Name(s): Brian Haqey Applicant Name: Brian Hagey <br /> Landowner Address: 8237 Emerald Terrace Applicant Address: 8237 Emerald Terrace <br /> Lodi, WI 53555 Lodi, WI 53555 <br /> Landowner Phone: (608) 628-8409 Applicant Phone: (608) 628-8409 <br /> LandownerE-mail: brianhagey@outlook . com ApplicantE-mail: brianhagey@outlook. com <br /> Name and company of engineer/consultant who prepared the plans: General Engineering Company <br /> Type of Permit: Erosion Control Shoreland Erosion Control <br /> (check only one) " (EC) (SE) <br /> Municipality:Town of Roxbury Section: 2 Quarter:NE Parcel#: 0907-024-0501-4 <br /> Fee Calculation <br /> Total Disturbed Area 6, 200 ft2 x$0.006/ft2 =$ 37 . 20 <br /> Total New Impervious Area 1, 979 ft2 <br /> (includes gravel) <br /> Total Redevelopment Impervious Area 1, 150 ft2 <br /> (includes gravel) <br /> Base Fee: Erosion Control(EC) $200 Base Fee=$ 400 . 00 <br /> Shoreland Erosion Control(SE)$400 437 . 20 <br /> Shoreland Erosion Control(SE)meeting criteria s. 11.05(2)(c)$200 Total Fee=$ <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 /> 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 />