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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- 1-S - ZS- <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 /> Michael C. Wussow <br /> Address Agent Address <br /> 3110 Waucheeta Trail <br /> City,State,Zip City,State,Zip <br /> Dunn, WI 53711 <br /> Phone Agent Phone <br /> 651-336-4600 <br /> E-Mail Agent E-mail <br /> mcwussow @gmaii.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 3110 Waucheeta Dunn/Section 5 % NE %% 2.369 <br /> Parcel Number(s) Zoning District <br /> 028/0610-051-4173-0 &028/0610-051-4162-3 R-2 <br /> CSM Lot 1 3 L , Subdivision Block/Lot <br /> Project Description t <br /> See attached. <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? ® Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes 0No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?INo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes liNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? 0 Ries E]No <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All 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 /> 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,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: 12-17-19 <br /> H\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />