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411 a i <br /> � �� <br /> Dane County Shoreland Zorii <br /> °� �,tick 3U' ,AY. oar <br /> Permit Application <br /> Application must be made in person aroit-eitoi,ilitgowAy__ <br /> Shoreland Zoning Permit fee is$150 _- <br /> !" r , <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 /> /�44.h , ein n, v_3 <br /> e <br /> Address Agent Address [� . <br /> 6's (6".,1,3- ‘,1 TT J� CEjV <br /> City,State,Zip City,State,Zip D <br /> ✓Ylarslot 11 , w L S-355-7 ,Ato� <br /> Phone Agent Phone 4 !U <br /> 7/s=�© _v / 206 <br /> E-Mail Agent E-mail DgNFDDU <br /> ` /I <br /> �,a�•C h r H H. fr-g fir, h�,,,,. � Co 4-✓t � ' <br /> ✓ �N PhD <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Sectio <br /> Acreage <br /> S4 3 � ,,<, Pf,1 T r /% <br /> has - <br /> Parcel Number(s) Zoning District <br /> de-026, /0$3, Vf672S% V /7o,/ 3 f6AO, 7freso.1 SI VO //)► ,!'/ <br /> 19/870. .t#c �D , 2.900t /1 -— <br /> CSM Lot Subdivision Block/Lot <br /> Project Description • <br /> /Q ., - <br /> � <br /> S et <br /> i <br /> r <br /> Please answer the following questions to the best of your ability: 0 i L a <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? ❑ Yes ❑No oC n t Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes Ck<o ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? lice If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes o <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All existing structures Permit Fee due at time of application <br /> ❑ Any 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 /> ❑ Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> ❑ 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. . <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. t <br /> Applicant signature: C- Date: 9J �7 "-2-Dg <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />