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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> t000' of a lake or pond 1W00' of lake, pond, river or stream ❑ 300' of a floodplain <br /> ❑ A floodplain ❑ 75' of a wetland ❑ A wetland, ❑�yThe vegetative buffer zone <br /> _Shoreland Water body: Identificatio�r� " 9 "�-DNR designated?-Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland <2 acres <br /> ❑ Floodplain FEMA map panel: 55025C Flood zone: <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage <br /> Lot <br /> ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area (square feet): Sq Ft <br /> Total Lot: <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot <br /> Primary building <br /> footprint "),–) <br /> Accessory building(s) <br /> Driveway <br /> Any other impervious <br /> Total impervious <br /> Percent impervious <br /> Project meets shoreland standards:1 'es ❑No Shoreland zoning permit denied: ❑Yes 'No <br /> Additional Dane County permits needed: \\ <br /> Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit EVariance <br /> ❑Floodplain development permit ❑ Zoning Permit . j <br /> Additional information required: pj)! 9 vsQ lr —C'X\S��� <br /> STATUS: Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> ❑ Shc eland zo .•ng permi on hold for other permits <br /> Issued b/—r _ _�� Date <br /> • s.tart onmg •. inistrat. <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />