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Dane County Shoreland Zoning <br /> Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- <br /> Application must be made in person Zoning Permit#DCPZP- <br /> Shoreland Zoning Permit fee is$l50 <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 Agent Name <br /> 1-e o i1 CA. L4- <br /> Address Agent Address <br /> 5321 SZ+- Rot. Ltj.3 4 kiDU rl <br /> City,State,Zip( City,State,Zip <br /> Lar 5311 <br /> Phone / Agent Phdne t <br /> (4104- Vt2--`?7 90 rit 0 <br /> E-Mail Agent E-mail <br /> i(p KL■A,-Q.Arirver Ltiv Q fysA, 1,, C.cl✓v1 <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section % %N_4 A 9 <br /> 53Z-7 lvc'San- A5 <br /> Parcel Number(s) Zoning District <br /> -252- $Zko - O 11--I <br /> CSM Lot Subdivision Block/Lot <br /> /37Eti Z <br /> Project Description <br /> Grcwr,..A C_,,\v.(44 ..t,oL.C+z me.+\.'+ qv.on grave polo, <br /> C narggQ_ 0 J <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?&Yes ONo 0 Don't Know <br /> Is there a wetland or floodplain on or near the property?ET Yes 0No 0 Don't Know <br /> Is this project associated with a recent rezone/CUP/variance?.No If yes, petition/appeal# <br /> Is this permit to correct a violation? D Yes'io <br /> Have you contacted the Dane County Land and Water Resources Department about this project?0 Yes lcifNo <br /> Most ap lications must be accompanied by a survey showing the following: <br /> 4/Property lines with dimensions <br /> 1 existing structures Permit Fee due at time of application <br /> y 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 /> g/ Ordinary High Water Mark a shoreland zoning permit is$150.00 and is <br /> ea/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,or a duly authorized representative,and may sign this permit application on the <br /> behalf of the owner(s)of said property. <br /> Applicant signature: Date: <br />