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ZONING PERMIT NO. Page 1 of 2 <br /> DANE COUNTY SHORELAND ZONING PERMIT DCPSHL-2016-00043 <br /> OWNER INFORMATION I AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> MARK KETELBOETER DANE COUNTY PARKS 608224 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> 8729 STATE HIGHWAY 19 5201 FEN OAK DR <br /> (City,State,Zip) (City,State,Zip) <br /> MAZOMANIE,WI 53560 MADISON, WI 53718 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> CLOSE.SARAH @COUNTYOFDANE.COM <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/41/4 <br /> 0807-091-8100-4 TOWN OF BERRY 9 NE NE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is 8729 STATE HIGHWAY 19 <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: New Structure/Addition r <br /> A-1 Ex Exclusive Ag Description:SNOWMOBILE BRIDGE REPLACEMENT t <br /> District <br /> Avg <br /> PROJECT INFORMATION App for Other.BRIDGE SEWER ` ,4 <br /> Septic �� <br /> REZONE NO. G.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND '.r <br /> YES 0 NO ® YES 111 NO YES ® NO • <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft. Sq.Ft <br /> Setback from Ordinary High Water Mark Water Body Name s ? t � <br /> HALFWAY PRAIRIE CREEK _ PERMIT FEE <br /> $0.00 <br /> I, the undersigned, am the owner of the property or an authorized agent acting on behalf of the owner of <br /> the property. I certify that the work to be performed, as part of this zoning permit, will be constructed as <br /> noted on the submitted plans and comply with the applicable zoning ordinances. I understand that failure <br /> to comply with any provision or condition of this permit renders this zoning permit null and void and subject <br /> to enforcement action. <br /> I acknowledge that I am responsible for complying with State and Federal laws concerning construction <br /> near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult <br /> to identify. Failure to comply may result in removal or modification of construction that violates the law or <br /> other penalties or costs. For more information, visit the Department of Natural Resources web page at <br /> www.dnr.state.wi.us or contact the Department of Natural Resources Service Center. <br /> I hereby consent to the entry on the permitted premises by Dane County zoning inspectors for the <br /> purposes of determining compliance with the zoning ordinances. <br /> Owner&Agent hereby agree to comply with all Dane County SIGNATUR Owner/Agee DATE.' <br /> Ordinances.Any unauthorized change from the information or /� <br /> plans submitted will invalidate the permit. t� <br /> ■111111A <br /> OFFieE USE ONLY (form version 01.01.00) <br /> DATE ISSUED NITIALS INSPECTION DATE INITIALS <br /> 06/30/2016 HJH3 <br /> DATE REVIEWED INITIALS <br />