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Dane County Shoreland Zoning <br /> zoning office use onty <br /> Permit Application <br /> 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 /> Chris James, Dane County Parks Zach Simpson <br /> Address Agent Address <br /> 5201 Fen Oak Drive, Room 208 910 W Wingra Dr. <br /> City,State,Zip Madison, WI 53718 City,State,Zip Madison, WI 53715 <br /> Phone 608-224-3763 Agent Phone <br /> 608-251 -4843 <br /> E-Mail Agent E-mail <br /> dames @countyofdane.com zach.simpson @strand.corn <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section <br /> 8565 Schoepp Rd 09/03 % %Nw �,1, NE Acreage <br /> Parcel Number(s) Zoning District <br /> 090703280200,090703280004,090703186107,090703185304 A-2, A-1 EX, B-1, & RE-1 <br /> CSM 04959 I Lot 3 I Subdivision Block/Lot <br /> Project Description <br /> Lussier County Park Boat Launch - Fish Lake <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? 8 Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? B Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes BNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes ❑W <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All existing structures Permit Fee due at time of application <br /> ❑ 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 /> ❑ 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. <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. <br /> Sarah Close Digitally signed k Sarah Close <br /> DN:on=Sarah rah@ o mane county Parks,ou, <br /> 8/3/16 <br /> • email=dase.sarah�counlyofdane.carn,c=US <br /> Applicant signature: Date:2016.08.0309:1558-0500' Date: <br /> HA\Zonina\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />