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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 /> • <br /> DATE 5-19 R — o APPLICATION NUMBER <br /> REQUEST FOR DETERMINATION OF: <br /> (F-ee for each item checked is $50.00. Make check payable to Dane county Zoning.) <br /> k- 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) re.44 Plains Section(s) 3a 1/4 1/4 (s) G714 -07e-se Se <br /> Tax ParcelNumber(s) o36 -34j-9 SiL-- - -- <br /> APPLICANT INFORMATION: <br /> Names) t-3� 4 go►1ri1 e, A l bre4 <br /> Mailing Address $9 bc,w..i,n1 ea , - -c. 1-ko vti.b t�� , 53512 <br /> Phone Number 41.0$- '298-o 30-2— <br /> Fax Number 6013- 83t- loot, <br /> Email Address 64,1 e-lbr�.w� <br /> Does the applicant own the property described above?0/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 /> ea /' . <br /> APPL •' I SIG ATURE DALE, <br /> E <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 wafer?) <br /> Existing or proposed use of the property described above <br /> knalication.doc 09/23/2004 <br />