Polk County Land Use Permit Application
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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
□
□
□
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Next page
Yes
No
1
2
3
Travel Trailer removed Y N
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