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Dane County Shoreland Zoning Zoning of use only <br /> Permit Application Shoreland Permit#:DCPSHL- <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 /> Jeel ttkA0 A■\\�.3ohAWk t—CCcst■ ek\V pbctCti CalvtgVeCA Vo,Nseci ll t ,x <br /> Address Agent Address ��( <br /> 'Z \� \r \s� a. 52-M 1� A Fa <br /> City,State,Zip City,State,Zip <br /> V‘C. r\ V\Cl vW ? " ` \k�� i N\1\ c ?cl\\ <br /> Phone one / Agent <br /> E-Mail Agent E-mail <br /> l*n-s? ?D Omail•COM eiTk A. a 1 -+lcshtck..Ccsw1 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> /P�1roperr�t'y�]Address `y'� `} Town/S1nectionl `�-f�rr Acreage <br /> '1/ V a\410\\1 C\-• ` vskr\ i n 1�, JV fir,Ii t\t\N t � <br /> Parcel Number(s) YY Zoning District <br /> Olk SOU\Q —017.--1t C-) —Ol IK- DCPRUL- OCCC-cocle <br /> CSM Lot Subdivision Block/Lot <br /> \' C-esa kk ? \c \3 <br /> Project Description <br /> Kem tx ( eA5�\' Ctf t p ) \ 5 \11v\ v\-e,‘, 5 41 ?2\Itr Pa <br /> \\ -do v1i1 <br /> -a\,i -*c1 , emtN\ Sk-Mte, in t^h- <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?1)(,Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property'? ❑ Yes ❑No 1%.Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?1No If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes l 1No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? r[Yes ❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> al Property lines with dimensions <br /> 4 All existing structures Permit Fee due at time of application <br /> 4 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 /> al 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. n <br /> Applicant signature.- 4-2\• `0\lc <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />