Fillable Polk County Tower Application printable pdf download

Polk County Tower Application

POLK COUNTY TOWER APPLICATION

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Make check (black ink) payable to:

Print Form

Mail in with fee - see table below

Polk County Zoning Department

COMPLETE ALL UNSHADED AREAS

MAKE CHECKS (black ink) PAYABLE TO:

Incomplete applications may be returned

100 Polk County Plaza, Suite 130

INCOMPLETE APPLICATIONS MAY BE RETURNED

Polk County Zoning Department

Erase Form

Balsam Lake, WI 54810

PLEASE PRINT – BLACK INK & RETURN ORIGINAL FORM

100 Polk County Plaza, Suite 130

(715) 485-9111, Mon-Fri, 8:30am-4:30pm

Balsam Lake, WI 54810

Property Address (Number & Street or Ave)

715-485-9111, Mon- Fri, 8:30am-4:30pm

Leasing Agent, Contractor, builder, OR Self

Property

Owner __________________________________________________________

Address

Mailing

Address _________________________________________________________

City

State

Zip

City _____________________________ State ________ Zip _____________

Phone Number

Mail permit to Contractor

□

(optional):_______________________________________________________

Yes

Phone Number:

__________________________________________________

PERMIT REQUESTED FOR: Fill in appropriate line

□

This

New Tower Fees:

New Tower

Permit Number

Fee: $

(includes address fee)

120’ or less

$500

column for

□

Collocation on Tower

Permit Number

Fee: $350

121’ to 160’

$1200

office use

(includes ground equipment)

160’ to 200’

$2100

□

only

Modify Transmission Facility

Permit Number

Fee: $350

200’ & up

$3000

LEGAL DESCRIPTION OF PROPERTY – SEE TAX BILL

Gov’t Lot

Parcel # / Computer #

Lot #

Subdivision/CSM #

___ ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___

__________ ¼ __________ ¼, Sec __________ / T _________N /R _________ W

Town of __________________________________

Size of parcel

Size of lease parcel (If applicable)

SQ FT

Acres

SQ FT

Acres

ADDITIONAL INFORMATION

Height of Tower

Cost of Project

Type of road your driveway is off of:

Name of Lake/Pond/River/Flowage

Collocation Available:

 US or State Hwy

 County Rd

 Town Rd

 Private Rd

 Yes 



Property Line Setback- 100% of the height of the tower- Unless an engineering report is provided by a professional

engineer that certifies that the tower is designed to collapse in the distance from the proposed tower location to the

property line.



Please provide one copy of the structural analysis and construction plans along with the other requirements of the

Telecommunication Towers, Antennas, and Related Facilities Ordinance with your application and fee.



Check with the town and other regulating agencies for additional regulations, permits or licensing that may be required.

The applicant, as witnessed by the applicant’s signature on this application hereby attests that the information contained therein and

any accompanying documents are accurate and true. Any assistance by County staff was at the applicant’s request. 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 site review.

Signature

Sign Here: ___________________________________ Date: _______________ □ Cash □Credit □ Check # _______

COMMENTS:

Office Use Only

Receipted/Issued by: ________________________________________

Date: ________________ Fee ________________

Date Received

Flood Plain

Zoning District

Runoff Rating

Lake Classification

□

 Yes 

Revised 4/26/2016

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Polk County Tower Application

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