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Dane County Shoreland Zoning Zoning office use only Permit Application Shoreland Permit#:DCPSHL-�G - O`l Application must be made in person Zoning Permit#DCPZP- Shoreland Zoning Permit fee is$150 A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County Zoning Division for any development within the shoreland district. Property Owner Information Agent Information Name Agent Name t-iNieK r i NA- R Ado h• Stet P//Y ilWood D sox)5 kiket r+w c/AA4404P S Address Agent Address 'z.Z 6" 6 o,wes+uatic( L..k) N•(, 787> 1444if City,State,Zip City,State,Zip Pa.IG.#;N e s 1. frob 6 7 fo RntGer (4,; 5 340 1 Phone Agent Phone 2.14 - 563 - 7408 668-412,0o78 E-Mail Agent E-mail T i NI%• 104r4 Q ran iky amt •C6+w 1 N Poe d.%90)..66Lo6-eVtvue •Co Property/Location Information (http://accessdane.co.dane.wi.us) Property Address Town/Section 44.1 S Acreage 5358 a•veI5 Prat DR• 1wcs#Parr TZZ. '�4�4 S.' Ac0.232 Parcel Number(s) Zoning District 0‘`/080q - ZZ4.4174• TZ, S t. )6.4ti CSM Lot Subdivision Block/Lot aitJeata Pile< Project Description Rer4,60e, T&RF. 2 • 64 >< `64 , ,,� i3 S 4uAe i;417e. / - - • 4610141 ck, A K pia"ct - Please answer the following questions to the best of your ability: Is the property within 300 feet of a stream or 1000 feet from a pond or lake? OrYes ❑No ❑ Don't Know Is there a wetland or floodplain on or near the property? ❑ Yes r to ❑ Don't Know Is this project associated with a recent rezone/CUP/variance?1 No If yes, petition/appeal# Is this permit to correct a violation? ❑ Yes yisio Have you contacted the Dane County Land and Water Resources Department about this project? 'Yes ❑No Most applications must be accompanied by a survey showing the following: ❑ Property lines with dimensions ❑ All existing structures Permit Fee due at time of application ❑ Any proposed structures Please have cash or check payment available ❑ All impervious surfaces at time of application submittal. Checks are ❑ All vegetative areas payable to Dane County Zoning. The fee for ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is ❑ Topographic data(2-foot contours) non-refundable. I,the undersigned,hereby make application for a shoreland zoning permit and certify to the accuracy of the information. I further certify I am the property owner,or a duly authorized representative,and may sign this permit application on the behalf of the owner(s)of said property. Applicant signature: Date:`G/2/aolto H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013