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BRIAN HENNING 12-2/750 26,„,i„` =, <br /> J ESSA K HENNING ' <br /> 65 COUNTY ROAD TT 4 <br /> M SHALL,WI 53559-8615 - DATE-/ / .2.0/..e ,,,, 1,. . gk:' _.g.41! <br /> PAY TO THE yJ � �� ! �� SHL <br /> ��JJ �./ <br /> ORDER OF QY"L �494"w�r 2064-4' <br /> �, ./ '� <br /> /�, " <br /> ®bank® <br /> i •d by the Dane County <br /> MEMO C(, p matron ._ <br /> 1:0 7 50000 2 21: L8 237095993011' 2698 <br /> 6S6 S �y� fi- R Tr ECEvE <br /> City,State,Zip City,State,Zip D <br /> ✓44r11-0 ii , W i ..C.?55-7 NOV Phone Agent Phone N 4 <br /> 7/s=570 -V-Y1% 2OI6 <br /> E-Mail <br /> Agent E-mail D <br /> ■ l <br /> g DANE COU <br /> .ti..-t.C�'1 Y N.t. �9©�Fyn,/ co 4-1.-7 .vi(yJ1fJN/, <br /> ‘2 A <br /> . Property/Location Information (http://accessdane.co.dane.wi.us) . <br /> • <br /> Property Address Town/Se Acreage <br /> 4.5� 3 (d,n/ ,,�T- ®/� v, v.�r, ,csS _,f <br /> Parcel Number(s) Zoning District <br /> /fSb2 b, /411,53, rlf47zsi y9/70,2 3 96'4 2?,,,, a sl f/o Al t/ <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> le.c,/.,et........_ t fd'- •-, 6'0 / , /2o <br /> .5 et <br /> .- f <br /> Please answer the following questions to the best of your ability: A ° <br /> �l <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? ❑ Yes ❑No ow <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ERI ❑C Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? EPNo If yes, petition/appeal# . <br /> Is this permit to correct a violation? ❑ Yes 2'No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes Ly'No <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 /> o Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> ❑ Topographic data(2-foot contours) <br /> 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 /> / , <br /> �tJ <br /> Applicant signature: _ -_- n <br /> ` " C Date: 7 J I7 "20/e <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />