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Permit # Date Permit Effective Date Permit Expires g:\data\dbases\forms\permit\word\erosioncontrollanddistpermit2012-02-21.doc 1 of 1 06/28/2012 EROSION CONTROL/LAND DISTURBING PERMIT APPLICATION CITY OF MIDDLETON 7426 HUBBARD AVE., MIDDLETON, WI 53562 [PHONE REDACTED] FAX [PHONE REDACTED] Area = S.F. Project Address Project Name and Description Applicant Address Phone Landowner Address Phone Plan prepared by I, hereby certify that I fully understand the provisions of the City of Middleton Erosion and Sediment Control Ordinance and Program, and that I accept responsibility for carrying out the Erosion and Sediment Control Plan for the above-referenced project as approved by the City. I further grant the right-of-entry onto this property, as described above, to the designated personnel of the City of Middleton for the purpose of inspecting and monitoring for compliance with the aforesaid Ordinance. I certify that all information is correct and that all pertinent City Ordinances will be complied with in performing the work for which this permit is issued. Landowners of construction sites with one or more acres of land disturbance including commercial building sites, need to obtain stormwater construction site permit from the Department of Natural Resources pursuant to subch. III of ch. NR 216, Wis. Adm. Code. DNR application forms and supporting information are available at: DNR's storm water program contact is Eric Rortvedt (273-5612; [EMAIL REDACTED]). Signature of Applicant Print Name Date APPROVED: City of Middleton Official Date Dane County Land Conservation 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.