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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 of 2 DCPSHL-2017-00053 OWNER INFORMATION AGENT/CONTRACTOR INFORMATION OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE BRIAN J MELL (608)444-0833 BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) 1964 BARBER DR (City,State,Zip) (City,State,Zip) STOUGHTON, WI 53589 E-MAIL ADDRESS E-MAIL ADDRESS PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 0610-264-1581-5 TOWN OF DUNN 26 SE NE PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE (Assignment of new address is 1964 BARBER DR subject to field verification.) LOT BLOCK I C.S.M.NO.or PLAT NAME 1 CSM 09113 ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: R-3 Residence 11837 Description:REPLACE GRAVEL DRIVEWAY WITH ASPHALT IN 11 District EXISTING LOCATION ¢ sack# :IF '_. �? PROJECT INFORMATION App for Other:DRIVEWAY SEWER `-* ',.A.I Septic ' `� REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION xw 1031 ❑ YES ® NO _. 7 ' SHORELAND FLOOD ZONE WETLAND IM:"-, 67 C ® YES 0 NO O YES ® NO ❑ YES ® NO _ , �' 4 ^ � "' °z �lxg � s Existing Impervious Proposed Impervious '�� ` ;. �� , '4¢ g� �- 1 Sq.Ft.3561 Sq.Ft.3561 _-4 r Setback from Ordinary High Water Mark Water Body Name '�'t �� 1 - LAKE KEGONSA 4:,,:400 ,, 'if*,` PERMIT FEE $150.00 I, the undersigned, am the owner of the property or an authorized agent acting on behalf of the owner of the property. I certify that the work to be performed, as part of this zoning permit, will be constructed as noted on the submitted plans and comply with the applicable zoning ordinances. I understand that failure to comply with any provision or condition of this permit renders this zoning permit null and void and subject to enforcement action. I acknowledge that I am responsible for complying with State and Federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or modification of construction that violates the law or other penalties or costs. For more information, visit the Department of Natural Resources web page at www.dnr.state.wi.us or contact the Department of Natural Resources Service Center. I hereby consent to the entry on the permitted premises by Dane County zoning inspectors for the purposes of determining compliance with the zoning ordinances. Owner&Agent hereby agree to comply with all Dane County SIGNATURE: Owner/� DATE: Ordinances.Any unauthorized change from the information or /J/ G plans submitted will invalidate the permit. —� �!� 7- IL( - 17 OFFICE USE ONLY (form version 01.01.00) DATE ISSUED INITIALS INSPECTION DATE INITIALS 07/14/2017 H J H 3 DATE REVIEWED INITIALS