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Dane County Shoreland Zoning Zoning office use only <br /> Permit Application Shoreland Permit ti:DCPSHL- - <br /> Application meet he made in person Zoning Permit II DCPZP- _ <br /> Shoreland Zoning Permit fee_is$150 <br /> A shoreland zoning Permit will he 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 /> NameAgent Name <br /> Mike Ayers Adam Carrico/Carrico Engineering <br /> Address 8692 Airport Rd Agent Address 1926 N Kollath Rd <br /> City,State,ZipMiddleton, WI 53562 City,State,Zip Verona, WI 53593 <br /> Phone 608-215-8949 Agent Phone 608-213-9718 <br /> E-Mail Agent E-mail <br /> ayers829@gmail.com adam@carricoengineering.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section ,� NW y,y, NE Acreage <br /> NA Springfield/30 1 .01 <br /> Parcel Number(s)056/0808-301 -8690-0 Zoning District Springfield-SFR <br /> CSM 15278 Lot 1 Subdivision NA [ Block/Lot NA <br /> Project Description <br /> Ayers wish to construct a single-family home on their lot located at above location.Entire lot is within shoreland zone due to drainageway/creek in rear yard <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 ONO ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? [1 Yes E•No ❑ Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? IENo If yes, petition/appeal It <br /> Is this permit to correct a violation? ❑ Yes EINo <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 /> o Property lines with dimensions <br /> All existing structures Permit Fee due at time of application <br /> uo Any proposed structures Please have cash or check payment available <br /> • All impervious surfaces at time of application submittal. Checks are <br /> payable to Dane County Zoning. The fee for <br /> o All vegetative areas <br /> o Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> o 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: G L� -,t/eo2 d <br /> Il:\Zoning\Shortland-WetlandZoning\Chapter II Forms\IX'PSHL_Application.docx Version 1.1 Created 12272013 <br />