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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> ❑ 1000' of a lake or pond ,J21\300' of lake,pond, river or stream ❑ 300' of a floodplain <br /> ❑ A floodplain ❑ 75' of a wetland CIA wetland ❑ The vegetative buffer zone <br /> Shoreland Water body:-s LG z,- Identification: v; .N►A r,,---cizJDNR designated )Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland<2 acres <br /> ❑ Floodplain FEMA map panel: 55025C Flood zone: <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage <br /> Lot <br /> - fisting ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area (square feet): <br /> Total Lot: € 35 Sq Ft <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot Gnu- %Li <br /> Primary building <br /> footprint <br /> Accessory building(s) <br /> Driveway <br /> Any other impervious <br /> Total impervious 3 a / 1-1 ( - _1 <br /> Percent impervious S A ) 5 /C <br /> Project meets shoreland standards Yes ❑No Shoreland zoning permit denied: ❑Yes` o <br /> Additional Dane County permits needed: <br /> ❑ Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit ❑Variance <br /> ❑Floodplain development permit Zoning Permit ❑ _ <br /> { <br /> Additional information required: <br /> ---) 1------) L- t L _... <br /> .. _ ___ _____ <br /> STATUS: ,Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> ,,, <br /> ❑ Shoreland z •' g permit on hld for other permits ,..... <br /> Issued by J ' Date v <br /> Assistant Zoning Administrator <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />