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Dane County Shoreland Zoning Zoning office use only <br /> Permit 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 /> Nan .1s( C kJ Agent Name <br /> ddress Agent Address <br /> SC) 1-.)„-dam 1-4, <br /> City,State,Zip City,State,Zip <br /> Phone Agent Phone <br /> 51619 <br /> E-Mail Agent E-mail <br /> Property/Location Information (http://accessdane.co.dane.w i.0 s) <br /> Property Address Town/Se ion <br /> Acre <br /> I%..s- <br /> yy /,iv <br /> Parcel Number(s) Zoning District <br /> a3c--7 l6 -i 1-7 o 4- <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> • ) i _g <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake?,31 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes=itco ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance^ No If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes OVo <br /> Have you contacted the Dane County Land and\Water Resources Department about this project? ❑ Yes 10 <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> Li <br /> existing structures Permit Fee due at time of application <br /> ❑ Any proposed structures Please have cash or check payment available <br /> ❑ All impervious surfaces at time of application submittal. Checks are <br /> Li <br /> All 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 /> Li Topographic data(2-foot contours) non-refundable. <br /> I the undersigned, hereby make application for a shoreland zoning permit and certify to the accuracy of the information. 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 said property. <br /> Applicant signature:- Date: <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Aonlication.docx Version 1.1 Created 12272013 <br />