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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER,,/�E <br /> 0��s U■-)d0 61 <br /> oning Status;CUP; <br /> OWNER ADDRESS (N mb r,Street,City,State,Zi ) <br /> �.L/Yf k2 k s e 7� / /- , Deed Restriction; CSM <br /> Y �1 amt�C�C !�! Van nce(# ) <br /> HOME PHONE CELL PHONE C! AILADDRESS <br /> ‘QcP 7Z-460 • G-Yyu , __ .5. G7114;/' : ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT •, E CONTRACTOR NAME <br /> [mil/�GI:G'v S' • 7- ['Site n' luding location <br /> AGENT ADDR' S CONTRACTOR ADmR SS Q of w eptic <br /> yyl kQ/°SerC� /tF <br /> (City,State,Zip) ( ity,State,Zip) etbacks <br /> w��{P1����S��, Site proval from <br /> PHONE PHONE n <br /> 6G 6—) 7O .-6) G 9 D appli township. <br /> E-MAIL AD''ESS E-MAIL ADDRESS <br /> " , C-Xtd G lo;plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURB ZONN : ACREAGE: i 1 5.1saa o n of property <br /> El NUMBER 9 O Q$ .�t4 %/609 <br /> —7, S frontage drawn to scale. <br /> TO SHIP: SE W& <br /> r� C 1/4: S %41/4: Drifts- .ermits <br /> ESS: <br /> Yi fri• (s - e,co,nty,town) <br /> 5 Er, Ke,l-e et- 70 <br /> Sani - •ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> PROPOSED PROJECT INFORMATION FF REVIEW <br /> PROJECT D CRIPTI9 N: <br /> (G.C� r(10 L, 1 e. /C, Zonin istrict <br /> ❑This project is a new building or structure. P rmitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> EWER PEPTIC (new <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> / r Wetly d O plain/ <br /> S d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) Erosion tr01 permit <br /> BASEMENT: 1ST FLOOR: <br /> 4. -.*� //' j TOTAL SQUARE FOOTAGE: j (SIOp , tur <br /> bann <br /> ce, <br /> fill'ng/acre ) <br /> 2ND FLOOR' <br /> 3RD FLOOR: / <br /> �! ❑ Review oc" ' n Survey <br /> ESTIMATED CONSTRUCTION COST: —lo. -1o. ♦ ♦ —I. —I. and av ' e options. <br /> (Please round to nearest dollar) $ 3 k <br /> i. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes IrNo DolMHfnow <br /> 2. Is there a wetland or floodplain on or near the property? [Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? INYes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes No ❑Don't know <br /> 7. Is this to correct a violation? Des JNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />