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ZONING OFFICE USE ONLY ZONING OFFICE USE ONLY <br /> Project includes development within: (check all that apply) <br /> ❑ 1000' of a lake or pond ❑ 300' of lake,pond, river or stream ❑ 300' of a floodplain <br /> ❑ A floodplain ❑ 75' of a wetland ❑ A wetland ❑ The vegetative buffer zone <br /> ❑ Shoreland Water body: Identification: DNR designated? ❑Yes ❑No <br /> ❑ Wetland ❑ Shoreland wetland ❑Inland wetland ❑Wetland<2 acres <br /> ❑ Floodplain FEMA map panel: 55025C Flood zone: <br /> ❑Floodway ❑Flood fringe ❑General floodplain ❑Flood storage <br /> Lot <br /> ❑Existing ❑ Existing non-conforming ❑New <br /> Impervious Surface Calculations <br /> Area(square feet): Sq Ft <br /> Total Lot: <br /> Within 300' of <br /> ordinary high water <br /> mark Existing Additional Proposed _ Post Development <br /> Lot <br /> Primary building <br /> footprint <br /> Accessory building(s) <br /> Driveway <br /> Any other impervious <br /> Total impervious <br /> Percent impervious <br /> Project meets shoreland standards: ❑Yes ❑No Shoreland zoning permit denied: ❑Yes ❑No <br /> Additional Dane County permits needed: <br /> ❑ Shoreland Erosion Control Permit ❑ Shoreland Mitigation Permit El Variance <br /> ❑Floodplain development permit ❑ Zoning Permit ❑ <br /> Additional information required: <br /> STATUS: ❑ Shoreland zoning permit and/or zoning permit issued contingent upon other permits <br /> ❑ Shoreland zoning permit on hold for other permits <br /> Issued by Date <br /> Assistant Zoning Administrator <br /> H:\Zoning\Shoreland-Wetland Zoning\Chapter 11 Forms\DCPSHL_Application.docx Version 1.1 Created 12272013 <br />