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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit#:DCPSHL- ! -7- <br /> .1 ppl/cation 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 /> Dan Oele Wisconsin Dept. Nat. Res. <br /> Address Agent Address <br /> 3911 Fish Hatchery Road 3911 Fish Hatchery Road <br /> City,State,Zip Fitchburg, WI 53711 City,State,Zip Fitchburg, WI 53711 <br /> Phone 608 275 3225 Agent Phone 608 275 3225 <br /> E-Mail Agent E-mail <br /> daniel.oele @wisconsin.gov daniel.oele @wisconsin.gov <br /> Property/Location Information (http://accessdane..co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> seabzse coiroroox�oye eroopry.wn saszt GPO<:ass: 2905N09E �a 1/41A see maps-78 total footprint <br /> Parcel Number(s)O5O9Z98OO 13 Zoning District <br /> A- I CEx) <br /> CSM Lot Subdivision Block/Lot <br /> Project Description <br /> see attached project narrative. <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 ENo ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? • Yes ❑No ❑ 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 BNo <br /> Have you contacted the Dane County Land and Water Resources Department about this project?1Yes ❑No <br /> Most applications must be accompanied by a survey showing the following: <br /> ❑ Property lines with dimensions <br /> ❑ All existing structures ermit Fee due at time of application <br /> ❑ Any proposed structures lease 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: c2 T/�"� Date: — <br /> 11.Voning\shoreland-Wetland Zoning\Chapter 11 Forms\DCPSt1L_Application docx Version 1 1 Created 12272013 <br />