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DANE COUNTY ZONING DIVISION <br /> DEPARTMENT OF PLANNING AND DEVELOPMENT <br /> 210 Martin Luther King, Jr. Blvd., Madison, WI 53703-3342 608.266.4266 <br /> DATE -S/d--Y/4 APPLICATION NUMBER pCPW1 / - <br /> REQUEST FOR DETERMINATION OF: <br /> ✓ NAVIGABILITY OF A STREAM <br /> WETLANDS STATUS OF A PROPOSED BUILDING SITE <br /> FLOODPLAIN STATUS OF A PROPOSED BUILDING SITE <br /> ORDINARY HIGH-WATER MARK <br /> (Fee for each item checked is $125.00. Make check payable to Dane County Zoning.) <br /> LOCATION OF DETERMINATION: <br /> Town(s) MIt)aL.-'1"6 t4 Section(s) t E 1/4 1/4 (s) 14k,...) p6 1-146 r4 v- <br /> Tax ParcelNumber(s) O` b$-“2-$E0L -tP ____ ___ ____ — <br /> Body of water for which this determination is being requested, if any. (Provide name of lake, <br /> river, creek, branch. For an un-named pond or stream, to which larger body of water is it a <br /> tributary or otherwise connected?) <br /> L)o N f s -rtE - ------ ------------ ------- --------------------------------------------------- <br /> E x i s t i n g or proposed use of the property described above: <br /> APPLICANT INFORMATION: <br /> Name(s) __� <br /> Mailing Address _ <br /> Phone ber <br /> F u • •r <br /> E a.: +• - s <br /> &.. _ __ _ 5--1--tc <br /> APPLI . NT SIGNATU' E DATE <br /> Does t e : • icant ow' the property described above? Ye . <br /> If NO, please submit a separate document with proof of the ownership of the property, property <br /> owner's name, address, phone number, fax number and email address as applicable. You must <br /> also provide a notarized statement signed by the property owner, authorizing you to apply for <br /> this determination. <br /> H:1Zoning\Zoning Division Documentation1Informational Materials\Forms\Determinations Application.doc <br /> Revised 06/26/2008 <br />