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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> ❑ 1000' of a lake or pond 1300' of lake, pond, river or stream 300' of a floodplain <br /> ❑ A floodplain ❑ 75' of a wetland ❑ A wetland ❑ The vegetative buffer zone <br /> ❑ Shoreland—Water body:u�ctwtecd cM-cA Identification: DNR designated? ❑Yes ❑No <br /> ❑ Wetland l� Shoreland wetland ❑Inland wetland ❑Wetland< 2 acres <br /> ❑ Floodplain FEMA map panel: 55025C O1-I 57 H. Flood zone: 'A <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage <br /> Lot <br /> 11Existing ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area (square feet): (N° <br /> Total Lot: t,-7 Kz yvv Sq Ft <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot 0 1,Z � s5 �E4. /, 2_00 I, . <br /> Primary building <br /> footprint 6-r)/,9(4) <br /> Accessory building(s) <br /> _ N/A <br /> Driveway N/A <br /> Any other impervious <br /> Total impervious <br /> Percent impervious <br /> Project meets shoreland standards: ❑Yes ❑No Shoreland zoning permit denied: ❑Yes ❑No <br /> Additional Dane County permits needed: <br /> ❑ Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit ❑Variance <br /> ❑Floodplain development permit ❑ Zoning Permit ❑ <br /> Additional information required: <br /> STATUS: ❑ Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> ❑ Shoreland zoning permit on hold for other permits <br /> Issued by Date <br /> Assistant Zoning Administrator <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter I I Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />