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DANE COUNTY ZONING DIVISION <br /> DEPARTMENT OF PLANNING AND DEVELOPMENT <br /> 210 Martin Luther King, Jr. Blvd., Madison, WI 53703-3342 608.266.4266 <br /> DATE F/g/6 APPLICATION NUMBER <br /> REQUEST FOR DETERMINATION OF: <br /> NAVIGABILITY OF A STREAM <br /> WETLANDS STATUS OF A PROPOSED BUILDING SITE <br /> FLOODPLAIN STATUS OF A PROPOSED BUILDING SITE <br /> ORDINARY HIGH-WATER MARK <br /> (Fee for each item checked is $125.00. Make check payable to Dane County Zoning.) <br /> LOCATION OF444 DETERMINATION: <br /> Town(s) Cu e Section(s) / ) 1/4 1/4 (s) !� XE <br /> Tax Parcel Number(s) 2// - /-�-? 0 �- Z <br /> - --- - ---- - ---- ----' - <br /> Body of water for which this determination is being requested, if any. (Provide name of lake, <br /> river, creek, branch. For an un-named pond or stream, to which larger body of water is it a <br /> tributary or otherwise connected?) <br /> 00r Cree---K- <br /> Existing o roposed e of the; ice described above: <br /> V: ti co 14 ev-t, t/c / ,f),1- fl- 1- 1'0 <br /> APPLICANT INFORMAT ON: / C Names) i ( I G O 4 004- 1- 4 ' G rrove- <br /> � y <br /> Mailing Address Lf �35 2 Y� <br /> �- 4S7- C6rt �: pie✓ 6vovc_ fo , I / <br /> Phone Number CO( , c �, w �e. <br /> Fax Number <br /> �✓ � �v.�� s �� S'e:� <br /> Email Address E uu"oft o� Yk sa - �D S, Ca�. 111-54 <br /> APPLICANT SIGNATURE DATE <br /> Does the applicant own the property described above <br /> If NO, please submit a separate document with proof of the ownership of the property, property <br /> owner's name, address, phone number, fax number and email address as applicable. You must <br /> also provide a notarized statement signed by the property owner, authorizing you to apply for <br /> this determination. <br /> H:\Zoning\Zoning Division Documentation\Informational Materials\Forms\Determinations Application.doc <br /> Revised 06/26/2008 <br />