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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> 1000' of a lake or pond 4300' of lake,pond, river or stream ❑ 300' of a floodplain <br /> El A floodplain ❑ 75' of a wetland ❑ A wetland nn ❑ The vegetative buffer zone <br /> Shoreland Water body: k j 11 rd- Identification: pn v p DNR designated? -Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland <2 acres <br /> ❑ Floodplain FEMA map panel: 55025C Flood zone: <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage <br /> Lot <br /> 1xisting ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area (square feet): <br /> Total Lot: S c Sq Ft <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed Post Development <br /> Lot "i°lam S <br /> Primary building <br /> footprint <br /> Accessory building(s) <br /> o ' 1Qe <br /> Driveway <br /> Any other impervious <br /> Total impervious L/ � ] q''1 <br /> Percent impervious ', �. )C'/d <br /> Project meets shoreland standardsYes ❑No Shoreland zoning permit denied: ❑Yeso <br /> Additional Dane County permits needed: \\ <br /> $Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit ❑Variance <br /> ❑Floodplain development permit ❑ Zoning Permit .14V- <br /> Additional information required: <br /> STATUS: ❑ Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> Shoreland ' .: g permit on ld for other permits <br /> Issued by Date <br /> A// <br /> � <br /> Assistant Zoning Administrator <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />