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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(# z.356 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (608)770-1800 o 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 Riva Ridge 323 S.Hale Street,Suite 100 <br /> (City,State,Zip) (City,State,Zip) IN Setbacks <br /> Racine,WI 53402 Wheaton,IL 60187 <br /> PHONE PHONE '4 Site Plan approval from <br /> (414) 788-1327 (218) 838-0081 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> nward @buellconsulting.com rickm @minnesotatowers.com 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: o Elevation of property <br /> Q PARCEL 026/0511-023-9001-1 37.40 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Dunkirk 2 14: SW WA: SW Driveway permits <br /> ADDRESS: (state,county,town) <br /> TBD <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Communications tower and ground equipment. ❑ Zoning District <br /> . P1 This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rural Address <br /> 1)EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 160.0 ❑ 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: 1-1 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) $ 140,000.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ✓❑Plo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes �/ o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? res DVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ao <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#2.356 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes EIVo ['Don't know <br /> 7. Is this to correct a violation? [Yes ✓7Vo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />