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ZONING PERMIT APPLICATION www.countyofdane.com r411 1a J"4"14C 11111[Cillt'a■TY_ .a <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / / / <br /> Ch et- 5 4 //41 /`011'( 1 El Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) / 1 Deed Restriction;CSM <br /> 75 l03 Sc�Tf©Ik b`Jc� v1• ,t7 P�'G/i.(�c w/ 535�/� Variance(# ) <br /> HOME PHONE 'CELL PHONE E-MAIL ADDRESS <br /> e7.5--- S?6 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -7ry Lai b ry5cw .4 ii e,,r/c c 6am, ,Ace�e 44,-1,./�-s El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of welUseptic <br /> / 2�4 L hf->"rv,(5 by,. 3' )I„ Lit,. hCr',,eif ,vV• <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 1)4-v(314.C4 (,.)( S 3 5943 ,, PocuviC : �/ s 3 5 5v <br /> PHONE t PHONE ❑Site Plan approval from <br /> ,2 3 S• / (o B. ;2 3 c - /g C, applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL r� I ` �1 frontage drawn to scale. <br /> NUMBER °!2 fJ/ll•g-2• Ma' `� �. i i /•J -Z CJ <br /> TOWNSHIP: SECTION: <br /> 81 (-S q/4: 1/4,A. ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 75(o 3 514 0 I k SA K '-e ��. S3 S <br /> CSM: LOT SUBDIVISION ( BLOCK/LOT ❑Sanitary permits <br /> 3 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> De 1-‹4_ 4 L d 6 R v4 y e ❑ Zoning District <br /> . his project is a new building or structure. <br /> ❑ Permitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEVVER 1EP11C (new/existing) <br /> HEIGHT IN FEET: � i NUMBER OF STORIES: (Not including basement) <br /> Ai- _ owe ❑ Wetland/Floodplain/ <br /> 7 AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: I—, <br /> ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 4 G ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ —Si. ♦ ♦ ♦ q ,n and available options. <br /> (Please round to nearest dollar) S I / mo, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑'lo on't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? :Yes ❑Vo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑Vo <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# Z-Tl/ ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Des 3o EJon't know <br /> 7. Is this to correct a violation? ❑Yeslo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - -+ <br /> 545.11,/W <br />