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DANE COUNTY <br /> ;APPLICATION FOR PERMIT TO DEVELOP IN A FLOOD PLAIN OR WETLAND PERMIT NO. FP 5-2(D L <br /> The undersigned hereby makes application for a permit to develop in a flood plain. The work <br /> to be performed, including flood protection works , is as described below and in attachments <br /> hereto. The undersigned agrees that all such work shall be done in accordance with the req- <br /> uirements of the Dane County Flood Plain Zoning Ordinance and with all other applicable <br /> County Ordinances and the laws and regulations of the State of Wisconsin. <br /> • <br /> LOCATION: <br /> 3°J L1 Lc, k-e- Sto►---e_ :/)r A-)kiv,.--) ac' Sr Ntt <br /> Number Road Town Sec 1/4 1/4 <br /> 3 Z EcAe -4,7,-. dam, /� Pe,tzk A- 3 <br /> Lot Block Subdivision or C.S.M. Number Zone <br /> PROPOSED WORK: BUILDING: FLOOD DISTRICT: AREA: <br /> Subdivision New General FP 71. x <br /> Filling Addition Regional FF Square feet / t So° <br /> Grading Alteration Regional FW RFE USGS <br /> Mineral removal Moving Top of fill USGS <br /> Dredging Z.P.# FIRM ZONE Cost <br /> Owner CONTRACTOR/BUILDER <br /> /30b A 1 i7 r jc-- S c, ,--c <br /> Zob .L i c. w`0 t(1rQ s f <br /> Signed:—A c e ___ ,/,_,/ O Date /a — /3 °2P <br /> Permit issued /o/i3)0 e Permit denied Reason <br /> Fee $ % 2S -tiv By: 5 f 0 /4- Sc Lvo-e_ i1-e .. 1< 1-t- Date iCy/,3fo , <br /> Inspection record: <br /> By: Date C of C issued By: <br /> Plans prepared by Date <br /> Land Surveyor/Engineer/Architect <br /> Sent to DNR District Main Office By <br /> Other information <br /> 545-44112!781 <br />