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U11 Accu SUPPLEMENT to Web-App # <br /> f`' ' <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Por«k- nniScr 2 Ve4iecsaer� <br /> �q j El Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Lo+ 10 Suss R., Co e Grove, h!1 5-3S,2'7 Variance(# ) <br /> HOME PHONE 1 CELL PHONE E-MAILAq DRESS <br /> 661-9344-109 N <br /> -y392 160$-3'13-`1S8 Iok jeMIS.4VQrta,'?. cw" ❑Site Plan drawn to scale <br /> AGENT INFORMATION • •- INFOFIMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Self'f' 5nNd ers Ex avakin, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ibo W L,'e+ec/oi,p Pass II/0 3 4312 V,'lo S F}ope RJ. <br /> (City,State,Zip) (City,State,Zip) p Setbacks <br /> Cotf-5 e (rove, hlr S35-o27 6.1401€ coie, WI s35-P <br /> PHONE PHONE ❑Site Plan approval from <br /> 60g- 807 - 7q 7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> off o e' sn der e 0• cop-) ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usf) ®Elevation of property <br /> PARENT PAR/ JJ07I37Jt ()o <br /> LNUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL ? /y frontage drawn to scale. <br /> ❑NUMBERaSFR-OS V.s <br /> TOWNSHIP: SECTION: <br /> Cotte t Gro RI 'la: SE 1A: S IN ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> Lo'' 10 Gass Rd. co-i4ole GroveW/ S"3 2') 2531 BASS RDI--, <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits 4 <br /> 389y I0 V. ' [MJ 40 Sky,' L, (public, private) BEDRI OMS <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> SFR WITH DECK, 4 BEDROOMS ❑ Zoning District <br /> This project is a new building or structure. U Permitted Use? YES <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Ip U Rural Address NEW <br /> EWER IZEPTIC 13. 9n/-00(0,- (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Rt 1 ❑ Wetland/Floodplain! N• <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> oo ' S f 3 3 'a Sf 4, TOTAL SOU ARE FOOTAGE: 4, (slopes, disturbance, N/1 <br /> SND FLOOR: 3RD FLOOR: filling/access) <br /> -5,3203f 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ —Ni. ♦ «t-445,000 and available options. Y S <br /> (Please round to nearest dollar) 6g, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 1lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Ekes ZNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ekes _No_.f4/A <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? fres at° <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Ses ; , ['Don't know <br /> 7. Is this to correct a violation? es ►: o <br /> CONDITIONS: SEPTIC SETBACK,TOPOGRAPHY WITHIN 5 FEET, LOCATION SURVEYAPPLICATION UST BE SIGNED <br /> (Continue on Back) <br /> REV(01/19) $582.00 -1.- -i -I. <br />