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DANE COUNT ZONING DIVISION <br /> DEPARTMENT OF PLANNING AND DEVELOPMENT <br /> 210 Martin Luther King,Jr.Blvd.,Madison,WI 53703-3342 608 266.4266 <br /> DATE 7-06 APPLICATION NUMBER <br /> REQUEST FOR DETERMINATION OF: <br /> (Fee for each item checked is-$50.00. Make check payable to Dane-county Zoning.) <br /> NAVIGABILITY OF A STREAM <br /> WETLANDS STATUS OF A PROPOSED BUILDING SITE <br /> FLOODPLAIN STATUS OF A PROPOSED BUILDING SITE <br /> ORDINARY HIGH-WATER MARK <br /> LOCATION OF DETERMINATION: <br /> Town(s) r 1;441 41 if, j Section(s) 1/41/4 (s) S. <br /> Tax Parcel Number(s) 070ry ---- _ _'____-- <br /> APPLICANT INFORMATION: <br /> cTef €v\ P &oc- <br /> Names) ,.. �: <br /> Mailing Address :,ice -? i: ` i l;' i L , <br /> Phone Number (.(;Y'7.) P .7 i 6 7 <br /> Fax Number "7 ro - 4 ; <br /> Email Address <br /> Does the applicant own the property described above? Y/N <br /> If NO,please submit a separate document with proof of the ownership of the property,property <br /> owner's name, address,phone number, fax number and email address as applicable. You must also <br /> provide a notarized statement signed by the property owner, authorizing you to apply for this <br /> determination. <br /> 5 I -OC <br /> '4' 'LIdANT SIGNATURE DATE <br /> Body of water for which this determination is being requested, if any. <br /> (Provide name of lake, river, creek, branch OR un-named pond or stream connected to <br /> or tributary to which larger body of water?) <br /> Existing or proposed use of the property described above <br /> h:\plandev\zoning\Forms'Determi.nations Application.doc 09/23/2004 <br />