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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- - <br /> Zoning Permit#DCPZP- - <br /> Application must be made in person <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 Cullen Vito Link Trust Agent Name Quam Engineering, LLC <br /> c. Address 3038 Shadyside Drive, Stoughton, WI 53589 Agent Address 4604 Siggelkow Rd,Suite A,McFarland,WI 53558 <br /> Phone 630-543-3010 Agent Phone 608-838-7750 <br /> E-Mail sjink502 @aol.com Agent E-mail rquam @quamengineering.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Township Pleasant Springs Section 30 1/4 SE ,14 y, SW Acreage.196 <br /> Parcel Number(s)0611-304-4023-3 Zoning District R-3 <br /> CSM Lot Subdivision Crystal Springs Park Block/Lot 3 <br /> Project Description <br /> Proposed house addition with outdoor open grate ramp over pervious surface and replace gravel drive with reinforced grass turf stabilizer. <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? B 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 El No <br /> Have you contacted the Dane County Land and Water Conservation Department about this project? El Yes BNo <br /> Application must be accompanied by a survey showing the following: (minimum requirements) <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. I <br /> further certify I am the property owner • : duly authorized representative,and may sign this permit application on the <br /> behalf of the owner(s)of :'• .ro <br /> Z-)5 — /S____ <br /> Applicant signature: I✓ Date: <br /> H:\Zoning\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Avalication.docx Version 1.0 Created 04012013 <br />