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626 <br /> ZONING PERMIT APPLICATION wwwcountyofdalle.Com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ) <br /> l�iSe 551 e'0JX oning Status;CUP; <br /> �s <br /> (Number,l � �) Deed Restriction;CSM <br /> 55(0$ P- \ ( <br /> FIOIAE CELL <br /> E-MAIL ADDRESS ` ` Variance # ) 1 ` <br /> $c)5-77--05— 4 e Plan drawn to scale 4E' <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions \ia5 l <br /> AGENT NAME CONTRACTOR NAME <br /> n j" <br /> ktitiael ,prat e gd �re5 A,P7tr',COi-, h cL?4e. gu,/kJ Utite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS A (J of well/septic 1 <br /> (ter.stye.Z) (city. ,zip) - Vbacks <br /> -iur pr.,,r:e_ w/ .535-10 <br /> PHONE NONE II e Plan approval from <br /> �I <br /> 19D D- 01-14/- 1773 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS j <br /> e,,-,the ,a i a , ,„C'c .4n , ui,u plans to scale <br /> PROPERTY LOCATION INFORMATION (http:-accessaane.co.dane.wi.us) levationof <br /> PARENT PARCEL NUMBER: CURRENTZOMNG: ACREAGE property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> /(0 1/4: $E 1/41/4: 54. k 4 f g fewaY Permits <br /> (state,/ V�^ (state,county,town) <br /> ADDRESS: <br /> (a0 nit'/) .I f' .nitary permits <br /> CSM: LOT SUBDIVISION BL OT (public,private) <br /> f033 22 fldlcred <br /> PROPOSED PROJECT INFORMATION /TAFF REVIEW <br /> PROJECT DESCRIPTION:A District <br /> IL'J This project is a new building or structure. <br /> ennitbed Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMT BER: ❑ Rural A s •. <br /> ❑SEWER KSEPTIC N p (new/ <br /> I-EIGHT IN FEET: 6 ' ' NUMBER OF STORIES: (Na inducing basement) ❑ <br /> / Shoreland (attachment)TO N ST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionCorttrol pemritt <br /> BASEMENT: <br /> O ,ST FLOOR: „ 2-q-'2- , TO1AL SQUARE FOOTAGE j (Slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: @ ,S(� '�- and available options. <br /> (Please round to nearest dollar) "+ $ (ff <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes a No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes '-t No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes INo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes El No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) peave blank if none) <br /> 6. Is a location survey required? (see reverse) Yes ❑No l':' Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> - . APPUCATION MUST BE SIGNED <br /> 1 NO (S (\� i't\--tilik ./�- (Continue on Back) -► -► -►. ).� ��:I t�J fN/ <br /> j v k(-7 /q0 900 3 -try o <br /> z7---24 9 I <br />