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Dane County Shoreland Zoning Zoning office use onty <br /> Permit Application Shoreland Permit#:DCPSHL- / /1 <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 /> Jason Hensen � S��J O u l l.i)r t S 2 L)C <br /> Address Agent Address <br /> 5116 Pheasant Branch Rd Ito go,..k•.01/ 5144,_ /3 <br /> City,State,Zip City,State,Zip <br /> Waunakee, WI 53597 1,,,)a,t, Q w'i 5 3 572 <br /> Phone Agent Phone <br /> 608-576 4572 60. 46- 1/4/3q1 — 1-(73 <br /> E-Mail, Agent E-mail <br /> �hensen85 @yahoo.com Hsu► (3J (leelf 4-.15 . nt.-+ <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section �.�. Acreage 2.02 <br /> 5188 Pheasant Branch Rd Springfield/25 % SE + + NW <br /> Parcel Number(s) Zoning District <br /> 056/0808-254-8690-0 <br /> CSM Lot 1 Subdivision Block/Lot <br /> 14721 <br /> Project Description <br /> Removal of existing house,driveway,and buildings.Construction of new house and driveway partially w/in 300'of an existing pond. <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? 8 Yes ❑No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? No 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? ❑ 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 /> Li <br /> proposed structures Please have cash or check payment available <br /> Li <br /> 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 /> Li 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. gevevlApplicant signature: � Date: 2-7Z- / <br /> H:\Zonine\Shoreland-Wetland Zonine\Chapter 11 Forms\DCPSHL Application.docx Version 1.1 Created 12272013 <br />