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DANE COUNTY SHORELAND ZONING PERMIT ZONING PERMIT NO. Page 1 oft <br /> DCPSHL-2017-00094 <br /> OWNER INFORMATION AGENT/CONTRACTOR INFORMATION <br /> OWNER NAME PHONE AGENT/CONTRACTOR NAME PHONE <br /> WI DNR (608) 275-3225 WI DNR (608) 275-3225 <br /> BILLING ADDRESS(Number,Street) ADDRESS(Number,Street) <br /> PO BOX 7921 3911 FISH HATCHERY RD <br /> (City,State,Zip) (City,State,Zip) <br /> MADISON, WI 53701-7921 FITCHBURG, WI 53711 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> DANIEL.OELE @WISCONSIN.GOV <br /> PARCEL NO. TOWNSHIP SECTION 1/4 1/4 1/4 <br /> 0509-292-8001-3 TOWN OF OREGON 29 NW NE <br /> PROPERTY ADDRESS HOUSE NO. ST.DIRECTION STREET NAME ST.TYPE <br /> (Assignment of new address is <br /> subject to field verification.) <br /> LOT BLOCK C.S.M.NO.or PLAT NAME <br /> METES AND BOUNDS <br /> ZONING DISTRICT PARCEL SQ FOOTAGE PROPOSED PROJECT: <br /> A-1 Ex Exclusive Ag Description.WI DNR HABITAT RESTORATION PROJECT <br /> District BELLEBROOK RD <br /> PROJECT INFORMATION App for Other:HABITAT RESTORATION SEWER <br /> Septic <br /> REZONE NO. C.U.P.NO. VARIANCE NO. DEED RESTRICTION <br /> ❑ YES ® NO <br /> SHORELAND FLOOD ZONE WETLAND <br /> YES 0 NO ® YES NO ® YES ❑ NO <br /> Existing Impervious Proposed Impervious <br /> Sq.Ft. Sq.Ft. <br /> Setback from Ordinary High Water Mark Water Body Name r <br /> STORY CREEK 'PERMIT FEE <br /> $0.00 <br /> I, the undersigned, am the owner of the property or an authorized agent acting on behalf of the owner of <br /> the property. I certify that the work to be performed, as part of this zoning permit, will be constructed as <br /> noted on the submitted plans and comply with the applicable zoning ordinances. I understand that failure <br /> to comply with any provision or condition of this permit renders this zoning permit null and void and <br /> subject to enforcement action. <br /> I acknowledge that I am responsible for complying with State and Federal laws concerning construction <br /> near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be <br /> difficult to identify. Failure to comply may result in removal or modification of construction that violates <br /> the law or other penalties or costs. For more information, visit the Department of Natural Resources web <br /> page at www.dnr.state.wi.us or contact the Department of Natural Resources Service Center. <br /> I hereby consent to the entry on the permitted premises by Dane County zoning inspectors for the <br /> purposes of determining compliance with the zoning ordinances. <br /> Owner&Agent hereby agree to comply with all Dane County ,N1�1AATURE: Owl . BATE: <br /> Ordinances.Any unauthorized change from the information or pN �I <br /> plans submitted will invalidate the permit. <br /> OFFICE USE ONLY (form version 01.01.00) <br /> DATE ISSUED INITIALS INSPECTION DATE INITIALS <br /> 12/20/2017 HJ H 3 <br /> DATE REVIEWED INITIALS <br />