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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> A1000' of a lake or pond 00' of lake, pond, river or stream 7300' of a.floodplain <br /> RA floodplain ❑ 75' of a wetland ❑ A wetland ❑ The vegetative buffer zone <br /> J . Shoreland Water body: Lo,ke „1 ,Identification: 1,-o-1"Q DNR designatell Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland<2 acres <br /> ,q Floodplain FEMA map panel: 55025C C)60°7 - b Flood zone: A E <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage to gz,IN7 <br /> Lot <br /> - Existing ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area (square feet): Sq Ft <br /> Total Lot: <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot <br /> Primary building <br /> footprint <br /> Accessory building(s) <br /> Driveway <br /> Any other impervious <br /> Total impervious <br /> Percent impervious <br /> Project meets shoreland standards:72;IYes ❑No Shoreland zoning permit denied: ❑Yes r2iNo <br /> Additional Dane County permits needed: <br /> %Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit ❑Variance <br /> ❑Floodplain development permit ❑ Zoning Permit ❑ <br /> Additional information required: 00 -e�p�s Ql� o f 1-,m r�J• s./,L 1-0 s c <br /> D <br /> STATUS: ❑ Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> 2rS •re . s 1 •o • g permit o, hold for other permits <br /> Issued by .mod Date 3 AC <br /> y sista Zonmg Administrator <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />