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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Don Squire Jr. <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2046 Norgaren Rd,Stoughton,WI 53589 Variance(# 9,355 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)770-1800 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Nathan Ward,Buell Consulting Minnesota Towers(Rick Mattson) ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1200 Rive Ridge 323 S.Hale Street,Suite 100 <br /> (City,State,Zip) (City,State,Zip) o Setbacks <br /> Racine,WI 53402 Wheaton,IL 60187 <br /> PHONE PHONE A Site Plan approval from <br /> (414) 788-1327 (218) 838-0081 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> nward @buellconsulting.com rickm @minnesotatowers.com IN Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Q Elevation of property <br /> n PARCEL 046/0611-271-8730-0 29.00 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Pleasant Springs 27 lh: NE �/4%/4. NW 15I Driveway permits <br /> ADDRESS: TBD (state, county,town) <br /> I ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 12,213 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Communications tower and ground equipment. ❑ Zoning District <br /> 0 This project is a new building or structure. <br /> LI Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 130.0 LI Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: I—, ErosionControl permit <br /> 10,000.0 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> 10,000.0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 125,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ✓�lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres ao ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes lslo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ✓iNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#2,355 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ao ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IVo <br /> • APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ ■ —► <br />