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Dane County Shoreland Zoning Zoning office use only Permit Application Shore land Permit#:DCPSHL-!fie - / Application must be made in person Zoning Permit#DCPZP- Shoreland Zoning Permit fee is$150 A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County Zoning Division for any development within the shoreland district. Property Owner Information Agent Information Name Agent Name f51 l Ron and Jeanette Agee �' 44,4 ,meyn ft:t4 — 015veS, I (C Address Agent Address 1018 Lincoln Avenue 5 F90 1 eA r City,State,Zip Ntale,`7Zi9_ �� } Stoughton,WI 53589 ck ,j �_i 53Ss-ST Phone Agent Phone 6C,8_ E3 8-mil f/O E-Mail Agent E-mail ron.agee @gmail.com e; 1 •{„] m So. ,� , M1VI rs, �,�m Property/Location Information (http://accessssddaalne.co.ddane.wi.us)) Property Address Town/Section Acreage 854 Hillside Road,Edgerton,WI 53534 Albion/14 �y SE %'' SE 11.235 Parcel Number(s) Zoning District PIN:051214495607 RH-3 DCPREZ-000-06070 CSM Lot Subdivision Block/Lot Project Description The project consists of:removing an existing house,constructing a new house and extending the driveway. The existing gravel driveway is to remain. Please answer the following questions to the best of your ability: Is the property within 300 feet of a stream or 1000 feet from a pond or lake? 8 Yes No ❑ Don't Know Is there a wetland or floodplain on or near the property? 8 Yes ❑No ❑ Don't Know Is this project associated with a recent rezone/CUP/variance? RNo If yes, petition/appeal# Is this permit to correct a violation? ❑ Yes BNo Have you contacted the Dane County Land and Water Resources Department about this project? ❑If es ❑No Most applications must be accompanied by a survey showing the following: ❑ Property lines with dimensions ❑ All existing structures Permit Fee due at time of application ❑ Any proposed structures Please have cash or check payment available ❑ All impervious surfaces at time of application submittal. Checks are Li vegetative areas payable to Dane County Zoning. The fee for ❑ Ordinary High Water Mark a shoreland zoning permit is$150.00 and is ❑ Topographic data(2-foot contours) non-refundable. I,the undersigned, hereby make applicatio' .r a shoreland zoning permit and certify to the accuracy of the information. I further certify I am the property o er, o .my authorized representative, and may sign this permit application on the behalf of the owner(s)of - pn.;rt / 5AApplicant signat re: `� Date: 34 H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013