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Dane County Shoreland Zoning Zrningoffice use only Permit Application Shoreland Permit M:DCPSHL- . Application must be made in person Zoning Permit#DCPZP- Shoreland Zoning Permit fee is 5150 • A shoreland zoning Permit will be required prior to a general zoning permit being issued by the Dane County Zoning Division for any development within the shoreland district. Property Owner Information Agent Information Name..., �(( Agent Name . y30/7 J(>/zz Address Agent Address c3Ls 2 X)v,e/Yv. n, p,) _ City.State,Zip City,State.Zip 7r -:3 - t't-- .37/ -- -Phone Agent Phone t3 q, E-Mail ,� Agent E-mail -...T1.!j 0i"P (S .S. '�j,!,f4.1 /'.��'�;. . eni Property/Location Information (http:llaccessdane.co.dane.wi.us) Property AddreTown;Sectivv�� Acreage ,r Parcel Number(s) Zoning District (X /° -.239- 95 c V CSM 1 Lot Subdivision Block/Lot Project Description k2/n4944-47) 0-61.4tttic4:402 ' ,,,,, Aar---6(<,/irt tJ Please answer the following questions to the best of your ability: Is the property within 300 feet of a stream or 1000 feet from a pond or lake? E Yes❑No❑ Don't Know Is there a wetland or floodplain on or near the property? El Yes 'o ❑ Don't Know Is this project associated with a recent rezone`CUP/variance?'No If yes, petition/appeal# Is this permit to correct a violation'? ❑ Yesslo Have you contacted the Dane County Land and Water Resources Department about this project'?kYes ❑No Most applications must be accompanied by a survey showing the following: ❑ Property lines with dimensions u All existing structures Permit Fee due at time of application u Any proposed structures Please have cash or check payment available at time of application submittal. Checks are u All impervious surfaces ❑ All vegetative areas payable to Dane County Zoning. The fee for u Ordinary High Water Mark a shoreland zoning permit is $150.00 and is a Topographic data(2-foot contours) non-refundable. I,the undersigned,hereby make applicatio. for a shoreland zoning permit and certify to the accuracy of the information. I further certify I am the property owne • . duly .. • orized representative,and may sign this permit application on the behalf of the owner(s)of said pr.:o •. . Applicant signatur, �S L Date: 0 H''Zonind.Shrnrland-Wetland 7,nin,fihanter 11 t i imi D 'PSH1. Annlicatinn r1nex Vrri„n 1 I Cr,.ii.•a 1"7.1)1;