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Dane County Shoreland Zoning Zoning c fCeuseonly <br /> Permit Application Shoreland Permit#:DCPSl3L- <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 p ior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within t 1 e shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> Scott Longua � ' <br /> C/°-55t C. C J o. . cAry 25 <br /> Address Agent Address <br /> 1727 Daily Drive <br /> 1 N CQA-„/ Pic <br /> City,State,Zip City,State,Zip <br /> Waunakee,WI 53597 ''// 5 sSq <br /> ) O✓,n 4 c--- L✓7- i T <br /> Phone Agent Phone <br /> (608)245-1361 (cell) I O S 0 ^1/q50 <br /> E-Mail 1 Agent E-mail <br /> slongua@gmail.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/.-ction Acreage <br /> 5390 Blue Bill Park Drive Wes port/Sec 22 +/, SE y,y, SW 0.23 <br /> Parcel Number(s) Zoning District <br /> 0809-224-4075-9 Erz <br /> CSM Lot Subdivision Block/Lot <br /> 5 1 Blue Bill Park <br /> Project Description <br /> The project consists of removing an existing house&driveway and constructing a new house and driveway. <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? U Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? U Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CU�/variance? BNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes UNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? Al des ❑No <br /> Most applications must be accompanied bvla 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 /> ❑ All 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: 6)1011--- <br /> Date: C a 14, <br /> II <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DC1bSHL_Application.docx Version 1.1 Created 12272013 <br />