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Dane County Shoreland Zoning Zoning office use only, <br /> Permit Application Shoreland Permit#:DCPSHL- - <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 /> John Barry Matt Hanna <br /> Address Agent Address <br /> 2934 Tracy Ln 190 Business Park Cir <br /> City,State,Zip City,State,Zip <br /> Stoughton, WI 53589 Stoughton, WI 53589 <br /> Phone Agent Phone <br /> 608-358-0406 608-235-6741 <br /> E-Mail Agent E-mail <br /> bad.ger@hotmail.com matt.hanna@moyersinc.net <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 2934 Tracy Ln. T06/30 % NE ,%% SE 1 .114 <br /> Parcel Number(s)046/0611-304-1002-4 Zoning District SFR-08 <br /> CSM Lot Subdivision Block/Lot <br /> 1 Kegonsa Park <br /> Project Description <br /> Remove and relocate impervious surfaces with a net decrease in impervious surface. <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 E Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes RNo E Don't Know <br /> Is this project associated with a recent rezone/CUP/variance? BNo If yes, petition/appeal# <br /> Is this permit to correct a violation? ❑ Yes .No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? E 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 /> Li Ordinary High Water Mark a shoreland zoning permit is $150.00 and is <br /> LiTopographic 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: <br /> H:\Zonine\Shoreland-Wetland Zonine\Chapter 11 Forms\DCPSHL Annlication.docx Version 1.1 Created 12272013 <br />