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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit 4:DCPSHL rFJ <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 prior to a general zoning permit being issued by the Dane County <br /> Zoning Division for any development within the shoreland district. <br /> Property Owner Information Agent Information <br /> Name Agent Name <br /> Mark & Lynda Ketelboeter Sarah Close <br /> Address Agent Address <br /> 8729 State Hwy 19 5201 Fen Oak Dr, Room 208 <br /> City,State,Zip City,State,Zip <br /> Mazomanie, WI 53560 Madison, WI 53718 <br /> Phone Agent Phone <br /> 608-224-3743 <br /> E-Mail Agent E-mail <br /> close.sarah @countyofdane.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) p <br /> Property Address 8729 State H 1 g Town/Section % NE +%�+%, NE Acreage 38.1 <br /> wY Mazomanie <br /> Parcel Number(s) Zoning District <br /> 004/0807-091-8100-4 <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> Replacing an existing wooden snowmobile bridge, existing structure is structurally unsound. <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? 8 Yes El No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes El No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? •No If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes El No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑des ❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> El <br /> 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 /> Digitally signed by Sarah Close <br /> DN:r�rSarah Close,o=Dane County Parks,ou, <br /> Sarah Close email-dosesarah @countyofdane.com,c=US 6/27/2016 <br /> Applicant signature: Dater 2016.06270921:46-05'00' Date:. <br /> H:\Zonine\Shoreland-Wetland Zoning\Chanter 11 Forrns\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />