"Polk County Land Use Permit Application" - Polk County, Wisconsin

Polk County Land Use Permit Application is a legal document that was released by the Wisconsin Department of Safety and Professional Services - a government authority operating within Wisconsin. The form may be used strictly within Polk County.

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Download "Polk County Land Use Permit Application" - Polk County, Wisconsin

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TO PRINT use button to right.
POLK COUNTY LAND USE PERMIT APPLICATION
Print
NO.
TAB to move between fields.
MAKE CHECKS (black ink) PAYABLE TO:
Original signature required.
Polk County Zoning Department
Mail application with fee.
Erase
COMPLETE ALL UNSHADED AREAS
100 Polk County Plaza, Suite 130
____________________________
INCOMPLETE APPLICATIONS MAY BE RETURNED
Allow 2 weeks to process.
Balsam Lake, WI 54810
PLEASE PRINT – BLACK INK AND RETURN ORIGINAL FORM
Fee
Incomplete applications may delay.
715-485-9111, Mon- Fri, 8:30am-4:30pm
PLEASE ALLOW 2 WEEKS TO PROCESS APPLICATION
Property Address (Number & Street or Ave)
Contractor/ Surveyor
Address
Property
City
State
Zip
__________________________________________________
Owner
Mailing
Phone
Mail permit
Yes
No
__________________________________________________
Number
to Contractor
Address
Previous
Date
City _______________________________ State ________ Zip _____________
owner
purchased
Adjoining
owner
Email
(optional): _______________________________________________________
Adjoining
Phone number: __________________________________________________
owner
LEGAL DESCRIPTION OF PROPERTY (Parent Parcel) – SEE TAX BILL
-- SEE TAX BILL
Parcel # / Computer # -- See tax bill
Lot #
Subdivision/CSM #
Gov’t Lot
___ ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___
Town of__________________________________
__________ ¼, __________ ¼, Sec __________ / T __________N /R __________ W
Size of Parcel
Name of Lake/Pond/River/Flowage (if applicable)
X
=
SQ FT
OR
Acres
PERMIT REQUESTED FOR: Fill in appropriate line(s) (BE SPECIFIC)
 Stick Built
Seasonal Y N
Walk out
Attached Garage
Size of Proposed Structure
Height
Number of Bedrooms
No
New
 Manufactured, year _______
Dwelling
Yes
No
Yes
No
X
=
SF
 Bunkhouse
Deck, Garage, Bedrooms, Vertical expansion, etc…
Size of Proposed Structure
Height
Existing
Additional
Addition to
Bedrooms
Bedrooms
Dwelling
X
=
SF
Garage, Boathouse, Shed, Farm Bldg , Seasonal Travel Trailer (1yr) Size of Proposed Structure
Height
Accessory
STORAGE ONLY NO
Building
HUMAN HABITATION
X
=
SF
Landscape, Retaining Wall, Patio, Stairs, Sign, Tourist Rooming
Size of Proposed Structure
Height
Number of Bedrooms
Other
house, etc…
X
=
SF
Minor Subdivision, Major Subdivision, Metes & Bounds Review
# of Existing
# Proposed
Subdivision
Town Checklist
Surveyor Review
Lots
Lots
Review
□ Yes □ No
□ Yes □ No
ADDITIONAL INFORMATION
Sanitary Permit
Type of road your driveway is off of:
Is project within 300’ of the ordinary high water mark?  Yes  No
Number:
If yes, please indicate total impervious area within 300’ of water: ___________________sq ft and
 US or State Hwy
 County Rd
divide by lot size within 300’ : ____________ sq ft = ____________%
 Town Rd
 Private Rd
If over 15%, please calculate the land use runoff rating to determine the amount of mitigation .
calculate
Cost of Project
A PLOT PLAN MUST BE PROVIDED (SEE BACK SIDE OR USE 8 ½ X11 SHEET OF PAPER)
I AGREE THAT THIS PERMIT IS SUBJECT TO ALL CONDITIONS AND APPLICABLE ORDINANCES
PROPOSED STRUCTURE LOCATION MUST BE STAKED FOR OPTIONAL ONSITE VERIFICATION
Contact your township for other requirements as a building or driveway permit and/or inspections may be required.
I declare that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and
belief it is true, correct, and complete. I agree to permit county officials charged with administering county ordinances or other authorized
person to have access to the above-described premises at any reasonable time for the purposes of inspection.
Office Use Only
Here:_____________________________ Date:________________ □ Cash □ Credit □ Check #_________
Signature
Sign
District: ____________
COMMENTS:
Office Use Only
Floodplain:
Y N
Revised 4/12/17
Issued by: ______________________________________ Date: __________________ Fee _______________
Date Received:
Mitigation Required:
Date Mitigation Filed:
Date Mitigation Completed: UDC Report filed: Y
Lake Classification
N
Next page
Yes
No
1
2
3
Travel Trailer removed Y N
TO PRINT use button to right.
POLK COUNTY LAND USE PERMIT APPLICATION
Print
NO.
TAB to move between fields.
MAKE CHECKS (black ink) PAYABLE TO:
Original signature required.
Polk County Zoning Department
Mail application with fee.
Erase
COMPLETE ALL UNSHADED AREAS
100 Polk County Plaza, Suite 130
____________________________
INCOMPLETE APPLICATIONS MAY BE RETURNED
Allow 2 weeks to process.
Balsam Lake, WI 54810
PLEASE PRINT – BLACK INK AND RETURN ORIGINAL FORM
Fee
Incomplete applications may delay.
715-485-9111, Mon- Fri, 8:30am-4:30pm
PLEASE ALLOW 2 WEEKS TO PROCESS APPLICATION
Property Address (Number & Street or Ave)
Contractor/ Surveyor
Address
Property
City
State
Zip
__________________________________________________
Owner
Mailing
Phone
Mail permit
Yes
No
__________________________________________________
Number
to Contractor
Address
Previous
Date
City _______________________________ State ________ Zip _____________
owner
purchased
Adjoining
owner
Email
(optional): _______________________________________________________
Adjoining
Phone number: __________________________________________________
owner
LEGAL DESCRIPTION OF PROPERTY (Parent Parcel) – SEE TAX BILL
-- SEE TAX BILL
Parcel # / Computer # -- See tax bill
Lot #
Subdivision/CSM #
Gov’t Lot
___ ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___
Town of__________________________________
__________ ¼, __________ ¼, Sec __________ / T __________N /R __________ W
Size of Parcel
Name of Lake/Pond/River/Flowage (if applicable)
X
=
SQ FT
OR
Acres
PERMIT REQUESTED FOR: Fill in appropriate line(s) (BE SPECIFIC)
 Stick Built
Seasonal Y N
Walk out
Attached Garage
Size of Proposed Structure
Height
Number of Bedrooms
No
New
 Manufactured, year _______
Dwelling
Yes
No
Yes
No
X
=
SF
 Bunkhouse
Deck, Garage, Bedrooms, Vertical expansion, etc…
Size of Proposed Structure
Height
Existing
Additional
Addition to
Bedrooms
Bedrooms
Dwelling
X
=
SF
Garage, Boathouse, Shed, Farm Bldg , Seasonal Travel Trailer (1yr) Size of Proposed Structure
Height
Accessory
STORAGE ONLY NO
Building
HUMAN HABITATION
X
=
SF
Landscape, Retaining Wall, Patio, Stairs, Sign, Tourist Rooming
Size of Proposed Structure
Height
Number of Bedrooms
Other
house, etc…
X
=
SF
Minor Subdivision, Major Subdivision, Metes & Bounds Review
# of Existing
# Proposed
Subdivision
Town Checklist
Surveyor Review
Lots
Lots
Review
□ Yes □ No
□ Yes □ No
ADDITIONAL INFORMATION
Sanitary Permit
Type of road your driveway is off of:
Is project within 300’ of the ordinary high water mark?  Yes  No
Number:
If yes, please indicate total impervious area within 300’ of water: ___________________sq ft and
 US or State Hwy
 County Rd
divide by lot size within 300’ : ____________ sq ft = ____________%
 Town Rd
 Private Rd
If over 15%, please calculate the land use runoff rating to determine the amount of mitigation .
calculate
Cost of Project
A PLOT PLAN MUST BE PROVIDED (SEE BACK SIDE OR USE 8 ½ X11 SHEET OF PAPER)
I AGREE THAT THIS PERMIT IS SUBJECT TO ALL CONDITIONS AND APPLICABLE ORDINANCES
PROPOSED STRUCTURE LOCATION MUST BE STAKED FOR OPTIONAL ONSITE VERIFICATION
Contact your township for other requirements as a building or driveway permit and/or inspections may be required.
I declare that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and
belief it is true, correct, and complete. I agree to permit county officials charged with administering county ordinances or other authorized
person to have access to the above-described premises at any reasonable time for the purposes of inspection.
Office Use Only
Here:_____________________________ Date:________________ □ Cash □ Credit □ Check #_________
Signature
Sign
District: ____________
COMMENTS:
Office Use Only
Floodplain:
Y N
Revised 4/12/17
Issued by: ______________________________________ Date: __________________ Fee _______________
Date Received:
Mitigation Required:
Date Mitigation Filed:
Date Mitigation Completed: UDC Report filed: Y
Lake Classification
N
Next page
Yes
No
1
2
3
Travel Trailer removed Y N
LOT LAYOUT
NORMAL HIGH WATER LINE
 Show location of ALL EXISTING
STRUCTURES in SOLID LINES
______ Feet
 Show dimensions, location and
(from eave)
setbacks of PROPOSED
STRUCTURE in DOTTED LINES
 Indicate: “D” dwelling, “A” accessory
building, “ST” septic tank, “DF”
drainfield
You will need to print
A
100’
application, then
complete drawing on this
______ Feet
______ Feet
24’
page or use 8 1/2 x 11
(from eave)
(from eave)
Deck
12’
sheet of paper to submit
60’
with application.
15’
40’
25’
D
35’
25’
25’
ST
DF
70’
Road Name
______ Feet
Center line of road or front property line
(from eave)
Back to page 1
Centerline of road or front property line
SHORELAND AREAS
H-1, R-1
A-1, A-2
(Land within 1,000’ of lakes, ponds & flowages or within 300’ of rivers or streams)
Incomplete applications
or RA-5
or A-3
may be returned.
STRUCTURES – Minimum setback
Class 1 &
Rivers/
from eaves
non-
Class 2
Class 3
Streams
Allow us 2 weeks to
Waterfront
process your application.
Dwelling
Ordinary High Water Mark
75 ft
75 ft
75 ft
75 ft
PLEASE check with your
Side lot line
10 ft
15 ft
25 ft
15 ft
10 ft
25 ft
Town building inspector to
Rear lot line
25 ft
25 ft
25 ft
25 ft
25 ft
25 ft
see if a building permit is
required for your project.
Accessory
Ordinary High Water Mark
75 ft
75 ft
75 ft
75 ft
Building
Side lot line
5 ft
10 ft
25 ft
10 ft
5 ft
25 ft
Permit information is public
Rear lot line
10 ft
10 ft
10 ft
10 ft
5 ft
25 ft
record and is available on
Polk County’s GIS
Boathouse
Ordinary High Water Mark
10 ft
10 ft
10 ft
10 ft
Website.
Private
Town
County
State or US Hwy
ROAD
Minimum setback
Road
Road
Road
Wetlands Notice: (WI Statute 59.691)
You are responsible for complying with state and
From center line
35 ft
63 ft
75 ft
110 ft
federal laws concerning the construction near or on
From right-of-way
--
30 ft
42 ft
50 ft
wetlands, lakes, and streams. Wetlands that are
SEWER
not associated with open water can be difficult to
Minimum setback
Dwelling /Accessory Building
Ordinary High Water Mark
identify. Failure to comply may result in removal or
Drainfield
10 ft
50 ft
modification of construction that violates the law or
other penalties or costs. For more information, visit
Septic Tank
5 ft
10 ft
the Department of Natural Resources wetlands
Dwelling
Accessory Building
Boathouse
HEIGHT LIMITS
identification web page or contact a Department of
Measured to the Peak
Natural Resources service center
35’
25’
14’ side wall
.
(lakeside)
http//dnr.wi.gov/topic/wetlands
http://dnr.wi.gov/topic/wetlands/
Farm Buildings Exempt from Height Limit
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