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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shore land Permit#:DCPSHL- - <br /> Application must be made in person Zoning Permit#DCPZP- - <br /> Shore land 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 /> Address Agent Address <br /> 5 5'7 9 Go tav, <br /> City,State,Zip City,State,Zip <br /> t W.A.a GA_ L S 3 S <br /> Phone I Agent Phone <br /> ços-.27 ¶ 90 5y E il t Agent E-mail <br /> K ro42_3 6,41E 1r1'10.�1 CO lrIN <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address ••�� Town/Section Acreage <br /> S-51 y L.3 oad �� k.�C� W p>ri- <br /> Parcel Number(s) Zoning District <br /> o�Q .-//7 - Q o <br /> CSM Lot Subdivision Blocl&�i� <br /> Project Description <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? ❑ Yes EINo ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes ENO ❑ 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 ENo <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes ❑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 /> ❑ Any proposed structures Please 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: Date: ! /2— t . <br /> f , <br /> H:\Zonine\Shoreland-Wetland Zonine\Chapter 11 Forms DCPSHL Aoolication.docx Version 1.1 Created 12272013 <br />