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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 /> Daniel & Cindy Brueck Premier Builders <br /> Address 102 N Holiday Drive Agent Address 102 N. Holiday Dr. <br /> City,State,Zip Waunakee Wi 53597 City,State,ZipWaunakee, WI 53597 <br /> Phone 608-849-6770 Agent Phone(608)849-6770 <br /> E-Mail Agent E-mail <br /> daniel.brueck@pfizer.com Jeanette@PremierBuilderslnc.com <br /> Property/Location Information (http://accessdane.co.dane.wi.us) <br /> Property Address Town/Section Acreage <br /> 6774 Wagner's Vineyar Bristol 30 % SE y,y, NW •071 <br /> Parcel Number(s)0911 -302-6425-0 <br /> umber(s)0911 -302-6425-0 Zoning District SFR <br /> CSM Lot Subdivision Block/Lot35 <br /> Bristol Gardens, Happy Valley Add <br /> Project Description <br /> New Home Construction <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? 8 Yes ENO ❑ Don't Know <br /> Is there a wetland or floodplain on or near the property? ❑ Yes MINo ❑ 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 •No <br /> Have you contacted the Dane County Land and Water Resources Department about this project? ❑ Yes 1111103 <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 /> , �, <br /> Applicant signature: Date: 6/23/2021 <br /> H:\Zoning\Shoreland-Wetland Zoning\Chanter 11 Forms\DCPSHL Anolication.docx Version 1.1 Created 12272013 <br />