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ZONING PERMIT APPLICATION www.countyofdan-� om rY'","4;,14aE'"4�-x`11 <br /> ,�. . <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME //�� <br /> 4- C)lJeeM (4)4 d ['Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 3 S At& v,-4 s �. Cojf49< �Z,�oc r (A) S 3 S-2? variance(# ) <br /> HOME PHONE CELL PHONE <br /> E-MAIL ADDRESS <br /> 03 / .S I (o z ,6) ea ❑Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -I-JAI Lai. beeSCiA A✓fri _ri'G€(,1 64, �;( 6k;l�n.s 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1.2 Olt 6‘4 retA ovit'sv be, SQL Lth n e euc.{ be . <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Ve Kc tJ ; S3S93 I7h 71ctrarY , liv.) i s3590 <br /> PHONE PHONE ❑Site Plan approval from <br /> -R 3-S • / 8(. Eb 3 S . l E).(0 b applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> E l NUMBER d 7(]�? ¢$O a j-.� R E I /, o 6 L frontage drawn to scale. <br /> TOWNSHIP: /, SECTION: <br /> (it4 I C, 1/4: '/4'/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> S '-s V;1 S RCA, 6-- ii/ Sl76DL1v13 ONE BLi" 5 3 5 2 7 ❑ ry permits <br /> Sanita <br /> CSM: LOT <br /> 0 O �/S / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Z 2 t Y 2+, 76.144441 4 Av/ic 6 C C'Zoning District <br /> . ®This project is a new building or structure. <br /> Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. r{� <br /> SANITARY SERVICE: PERMIT NUMBER: y� <br /> Rural Address <br /> FIEVVER riEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> j 2 ' Coe. ❑ Wetland/Flo / <br /> Shoreland ( a t) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: �, 1ST FLOOR: ❑ Ero IQ' ••ntr01 permit 4 TOTAL SQUARE FOOTAGE: 4 (SI•* ,.`f urbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/ ccess) <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ / 0,- and available options. <br /> (Please round to nearest dollar) $ / S' o , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es Vo on't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes r4 o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 2 o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes DVo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) J'es o don't know <br /> 7. Is this to correct a violation? [Yes �lo <br /> APPLICATION MUST BE SIGNED <br /> 511S-11/rnrrwi <br /> (Continue on Back) -♦ —► <br />