Application For Special Use Permit Form - Lee County
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1Date: _______________________
Permit # _________________________
Tax Map # ___________________
Deed Book # ____________________ Page # __________
Deed Document # _______________
Lee County
Application for Special Use Permit
(1) ______________________________, hereinafter called the applicant, hereby makes to the Lee
County Board of Supervisors for a Special Use Permit pursuant to 4.4 A (6) of the Lee County Zoning
Ordinance as adopted on December 14, 1990.
The Special User Permit hereby requested to be reviewed by the Zoning Administrator and
referred to the Board of Supervisors is for a(n)
(2)______________________________________________________________________________
type of facility which shall be located on (3) ______________________________________________
approximately (4) __________________________________________________________________
in what is know as the (5) ____________________________________________________________
said tract of land consisting of (6) _______________________________ acres, more or less, owned
by the applicant.
Wherefore, in consideration of the above, the applicant, (7) ____________________________
hereby requests that he be granted a Special Use Permit to operate the facility and avers that said
operation and use of said facility will have no foreseeable adverse impact on adjacent and proximate
property owners or in Lee County in general.
The Applicant hereby agrees to adhere to any reasonable conditions as may be necessary to
promote the objectives of the Zoning Ordinance and to mitigate the actual or potential adverse effects
of the proposed use and to that end, we respectfully request the said Special Use Permit be granted
to the Applicant pursuant to said Ordinances.
Respectfully Submitted
(8)_______________________________
Planning Commission meeting
Applicant’s Signature
planned for __________________
(9)_______________________________
at _______________ p.m
Applicant’s Print
(10)________________________________
____________________________________
Board of Supervisors meeting
Applicant’s Address
planned for __________________
at _______________ p.m
(11)_________________________________
Applicant’s Telephone Number
Fee Charged: ___________________
Collected as – Check # _____________
Cash ________________
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