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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1 <br /> wc. i►4n� s ra ❑Zoning Status;CUP; <br /> OWNER ADDRESS Number,Street,City,State,Zip) /� <br /> 5621 ��'e�� f 17+"r J,a.�/udder,,w,� r7 37/ . Deed Res ction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS (# ) <br /> 6°11S L2.610 2 44 "4 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT�NAME� CONTRACTOR NAME <br /> / <br /> ►� " '""'�'/ ':ezi h6r5 frec+evi ,- Con Sfdc..hoh 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR SS of welVseptic <br /> ?. t)4. 6-4.61-0), /204?.gl Po.50s. z-34 <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> Coifa-ffe•rove.(44I 5312.7 Cot ay L n,v'e., VVr 5-352_7 <br /> PHONE PHONE ❑Site Plan approval from <br /> 608. 234 .12 S 2. 608, 676'. 0405 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Mfe{999 e.901 • iav1, GGwi_e_4o4..aary)--, ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ['Elevation of property <br /> I:A N MBER 6711,04-1.8011.5 /`Jj-4- 2-0. 28 frontage drawn to scale. <br /> TOWNSHIP: SECT : <br /> CO11�Q �.r.0Ate-- <br /> ,/: N[ ,/% ❑Driveway permits <br /> (state,county,town) <br /> n)ADDRESS J <br /> None <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Zos iv1 CiAaAlloZ,0 VI 0.754&CAg_RH-4 .ho s-I 1 3O 4 b St ❑ Zoning District <br /> ®,This project is a new building or structure. <br /> 0 Permitted Use? <br /> []This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER F.—PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 1—, ErosionControl permit <br /> i Zoc 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: — filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED <br /> lease round ED CONSTRUCTION COST: ♦ i _, -► i and available options. <br /> Please r to nearest dollar th� <br /> Rd-cal/ion/--0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es 0lo QDon't know <br /> 2. Is there a wetland or floodpl�in on or near the property? r '? Res <br /> go ['Don't know <br /> 3. Have you taledwith the t ✓%ip about your protect and are they in agreement Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes VIN1 o <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. ao ['Don't know <br /> 7. Is this to correct a violation? Eyes 'lo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) <br /> (Continue on Back) ■ -► <br />