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, 40 <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Yellow Dog Farmstead/ Jeff & Carolyn Ball <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> W8976 County Road C, Fort Atkinson, WI 53538 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)423-9933 (608)213-9068 jeffbal161 @gmail.com ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Jeff Ball ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> W8976 Conty Road C <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Fort Atkinson, WI, 53538 <br /> PHONE PHONE ❑Site Plan approval from <br /> (608) 213-9068 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> jeffball61 @gmail.com ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane-wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT'ONING: ACREAGE: <br /> ❑PARCEL 24/0712-244-9002-0 A-1 (EX) 35.00 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Deerfield 24,712 1/4: SW 1/+/,: SE ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 76 Fair Oak Road, Deerfield, WI <br /> GSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 2,853 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRI N: <br /> per+ - s„`,-�` p r� t. tria 14V t`i_L,,� ❑ Zoning District _ <br /> . IS This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> [EWER v EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Jr 1.0 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance,. <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 51eL 51►o LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ $ Ire and available options. <br /> (Please round to nearest dollar) `� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ES No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes E✓No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes IN No <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) [Yes No ❑Don't know <br /> 7. Is this to correct a violation? :Yes ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -i <br /> 545-112(4/08) <br />