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C:\Documents and Settings\dmontour\Local Settings\Temporary Internet Files\Content.Outlook\5Q67J7ZL\StormWaterPermit2010-01-01.doc 1 of 1 STORM WATER RUNOFF CONTROL PERMIT APPLICATION CITY OF MIDDLETON 7426 HUBBARD AVE., MIDDLETON, WI 53562 [PHONE REDACTED] • FAX [PHONE REDACTED] Project Address Project Name and Description Pre-Existing Impervious Area = S.F. New Impervious Area = S.F. (constructed prior to 08/22/2001) (proposed, this project) Existing Impervious Area = S.F. Other Land Disturbance Area = S.F. (constructed after 08/22/2001) (existing pervious or impervious, disturbed this project) APPLICANT LANDOWNER PLAN PREPARER Name Address Phone ATTACHMENTS Plan Submittal Checklist Site and Grading Plans, including final revisions Storm Water Calculations Recorded Maintenance Agreement I, hereby certify that all information herein and attached hereto is correct, that I fully understand the provisions of the City of Middleton Storm Water Runoff Control Ordinance and Program, and that I accept responsibility for carrying out the Storm Water Runoff Control Plan, in full compliance with all pertinent City Ordinances, for the above-referenced project as approved by the City. I understand that the Permit Application Fee is non-refundable and must be paid at the time of permit submittal. I further acknowledge on behalf of the landowner that the City of Middleton has the right to designate personnel to enter the project premises for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. Per City Ordinance 26.10(7)(d), Permit Applicant or designated agent must contact a representative of Dane County Land Conservation, as agent of the City Engineer, at least two business days prior to installation of storm water management practices. Said representative must be present during construction. Signature of Applicant Print Name Date Permit # Permit Effective Date APPROVED: City of Middleton Official Date Dane County Land Conservation Division Official Date Date paid Receipt # Permit Fee $250.00 Permit fee must be paid before Dane County review will begin. In addition to the permit fee, the applicant shall pay the actual costs incurred by the City from any consultants or agents with whom the City may contract to provide services relating to the administration of this Code. The City shall bill the applicant for such charges, which shall be paid within 30 days. Any unpaid charges shall be assessed to the subject property as a special charge pursuant to Wis. Stats. 66.0627 and placed on the tax roll.