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Dane County Shoreland Zoning Zoning office use oniy <br /> Permit Application Shoreland Permit#:DCPSHL- � - 3S <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shoreland Zoning Permit fee is$150 <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 /> Gerald E Flynn Formecology, LLC <br /> Address Agent Address <br /> 3406 Quam Drive 210 Cemetery Road <br /> City, State,Zip City,State,Zip <br /> Stoughton, WI 53589 Evansville, WI 53536 <br /> Phone 608-630-1051 Agent Phone 608-882-6656 <br /> E-Mail Agent E-mail <br /> admiralsqueaky @gmail.com john.g @formecology.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 3406 Quam Drive TO6NR10E/25 ' %v •20 <br /> Parcel Number(s) Zoning District <br /> 028/0610-253-3175-6 R-3 DCPREZ-0000-00813 <br /> CSM Lot Subdivision Block/Lot 1 4 <br /> Project Description <br /> Remove replace concrete stoop/pad&driveway(614 sf),install drainage pipe&timber retaining wall,regrade areas&mulch(500-900sf) <br /> Please answer the following questions to the best of your ability: <br /> Is the property within 300 feet of a stream or 1000 feet from a pond or lake? B Yes ❑No ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ❑No B Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes •No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? El es ❑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 /> ❑ 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. 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 /> Applicant signature: Date: <br /> H:\Zonine\Shoreland-Wetland Zonine\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />