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Dane County Shoreland Zoning Zoning office use only <br /> .l errnit Application Shoreland Permit#:DCPSHL- - <br /> Application must be made in person . Zoning Permit DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <br /> A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> 0 061490 A- TnNya 3U411Ner 1"4_49.,-P. f o,-Waal <br /> Address Agent Address <br /> �13 8 v e Aue, 2so r 1n nottlfatat Lam,Su:t� lo <br /> CI y State,ZI City,State,Zip <br /> rit'AA <br /> G‘SON 533-0Y rc�,soi , wi 53 <br /> Phone i <br /> Agent Phone <br /> 6,D g - ,5-1 2- - 605-2 6c6 250 ?243 <br /> E-Mail Agen E-mall <br /> `fi'lauehoer 1020£9mti•►1 •toy ?-fri{age..eiy3e--;PIC.hel- <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Ap dr ss Town/Section Acreage <br /> r SG' i r 56—r¢321Vaitz_ Corc rh ;/ - Y•?tV 1c0\LS 36 a <br /> 40 <br /> Parcel Number(s) Zoning District <br /> 66Vdc/0Q -.363- 660¢-0 R—I <br /> CSM Lot Subdivisi Block/Lot�a � o lie.:(r �U <br /> . Project Description <br /> 1/eu 5i45l_raig4.4i hh Cns4c4,4. <br /> Please answer the following questions to he best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? /Yes DNo ❑Don't Know <br /> I <br /> Is there a wetland or floodplain on or near the property?❑Ye9�N0 0 Don't Know j <br /> Is this project associated with a recent rezone/CUP/variance?kri\10 If yes, petition/appeal#_____ . <br /> Is this permit to correct a violation? D Yes O'fVo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? Ld Ycs DNo <br /> • Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> a All existing structures Permit Fee due at time of application i <br /> ❑ Any proposed structures Please have cash or check payment available <br /> CI <br /> impervious surfaces at time of application submittal. Checks are <br /> El <br /> vegetative areas payable to Dane County Zoning. The fee for <br /> ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> ❑ Topographic data(2-foot contours) non-refundable. <br /> i <br /> I,the undersigned,hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I i <br /> further certify I am the property owner,or a duly authorized representative,and may sign this permit application on the <br /> behalf of the owner(s)of se' rty. /I 7C 4 h-e� —_�3, �S <br /> GjaOc�''' �G` <br /> Applicant signature: ��, _ � �,c/, Date: 7) J Z 3 1 L S` <br /> H:\Zoning'Shoreland-Wetland Zoning\Chapter 11 Forms\D 'SHL_Application.docx Version 1.1 Created 12272013 <br />