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Dane County Rezone & Application Date Petition Number <br /> 02/16/2016 DCPREZ-2016-10966 <br /> Conditional Use Permit Public Hearing Date C.U.P.Number <br /> 5/10 /(o 2e4er <br /> OWNER INFORMATION AGENT INFORMATION <br /> OWNER NAME PHONE(with Area AGENT NAME PHONE(with Area <br /> MICHAEL D SAMUEL Code) ISTHMUS SURVEYING LLC Code) <br /> (608) 514-4882 (608)244-1090 <br /> BILLING ADDRESS(Number&Street) ADDRESS(Number&Street) <br /> 440 STATE HIGHWAY 78 450 N BALDWIN ST <br /> (City,State,Zip) (City,State,Zip) <br /> MT HOREB, WI 53572 MADISON, WI 53703 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> MIKEANDNANCY @TDS.NET ISTHMUSSURVEYING @SBCGLOBAL.NET <br /> ADDRESS/LOCATION 1 ADDRESS/LOCATION 2 ADDRESS/LOCATION 3 <br /> ADDRESS OR LOCATION OF REZONE/CUP ADDRESS OR LOCATION OF REZONE/CUP ADDRESS OR LOCATION OF REZONE/CUP <br /> 440 STATE HIGHWAY 78 440 STATE HIGHWAY 78 <br /> TOWNSHIP SECTION TOWNSHIP SECTION TOWNSHIP SECTION <br /> PERRY 29 PERRY 29 <br /> 0506-293-8000-9 0506-294-8500-3 <br /> REASON FOR REZONE CUP DESCRIPTION <br /> CREATING ONE RESIDENTIAL LOT <br /> 197 Fl3QM DIiTRC7 ta� � � w� T O DiSTft1 <br /> „0r ****:*lN*cQ?. 0l;piNAN4'S* Q 1 AGIt <br /> A-1 Ex Exclusive Ag RH-2 Rural Homes 3.61 <br /> District District <br /> RH-1 Rural Homes RH-2 Rural Homes 2.75 <br /> District District <br /> C.S.M REQUIRED? PLAT REQUIRED? DEED RESTRICTION INSPECTOR'S INITIALS SIGNATURE:(Owner or Agent) <br /> REQUIRED? <br /> ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No <br /> SJW3 <br /> Applicant Initials Applicant Initials Applicant Initial PRINT NAME: <br /> COMMENTS: CREATION OF A RESIDENTIAL LOT L ' <br /> • E: <br /> CSM/DOC#: l`ia 9 g/S _S tst-1 17 <br /> DEED RESTRICTION: Form Version 03.00.03 <br /> DEED NOTICE: <br /> OTHER: <br />