Preliminary Minor Land Division Application Form - Rock County Planning, Economic & Community
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2ROCK COUNTY PLANNING, ECONOMIC & COMMUNITY
AGENCY USE ONLY
DEVELOPMENT AGENCY
51 SOUTH MAIN STREET
JANESVILLE, WI 53545
Application Number: __________________________
TELEPHONE: (608) 757‐5587
Received By – Date
FAX: (608) 757‐5586
(MM/DD/YYYY): __________________________
EMAIL: PLANNING@CO.ROCK.WI.US
WEB:
PRELIMINARY MINOR LAND DIVISION – APPLICATION FORM
**PLEASE DO NOT COMPLETE THIS APPLICATION FORM UNTIL YOU HAVE READ THE ROCK COUNTY
PRELIMINARY MINOR LAND DIVISION – APPLICATION FORM INFORMATION. PLEASE COMPLETE BOTH PAGES
OF THIS FORM AND PREPARE A MAP CONTAINING ALL INFORMATION AS IDENTIFIED ON PAGE 2 OF THIS FORM.**
1.
Applicant has contacted Town, Rock County Planning, Economic & Community Development Agency, and City(s)/Village
(if land division is within Extra‐Territorial Plat Approval Jurisdiction (ETJ) area) officials and these parties have determined
land division is feasible:
Yes
No
2.
Land division is consistent with Town’s Comprehensive Plan – Future Land Use Map:
Yes
No
3.
Land division area is located in a Farmland Preservation zoning district certified by the State of Wisconsin:
Yes
No
4.
5.
If you answered Yes, proceed to
If you answered No, proceed to
4.
Land division meets Town Base Farm Tract and any other applicable Farmland Preservation zoning district requirement:
Yes
No
5.
Land division will require a zoning change:
Yes
No
APPLICANT INFORMATION
6.
LANDOWNER OR AUTHORIZED LANDOWNER REPRESENTATIVE
a. Name:
Telephone:
Address:
City:
State:
Zip:
b. Name:
Telephone:
Address:
City:
State:
Zip:
7.
AGENT (SURVEYOR AND DEVELOPER)
a. Surveyor name:
Telephone:
Address:
City:
State:
Zip:
b. Developer name:
Telephone:
Address:
City:
State:
Zip:
8.
6.
7.
Identify the individual from
or
that will serve as the primary contact:
6a.
6b.
7a.
7b.
LAND DIVISION INFORMATION
9.
Reason for land division:
Sale/ownership transfer
Farm consolidation
Refinance
Other:
Town of
1/4 of
1/4
10.
Land division area location:
Section
Tax parcel number(s) ‐
11.
Land division area is located within the Extra‐Territorial Plat Approval Jurisdiction (ETJ) Area of a City(s)/Village:
Yes
No If Yes, identify: City(s)/Village of
12.
Land division area is located adjacent to (check all that apply):
Local/Town road
County highway
State highway
U.S. highway
13.
14.
15.
Landowner’s contiguous property area
Land division area
Current zoning of land division
(Square feet or acres):
(Square feet or acres):
area:
16.
17.
18.
Number of new/additional lots created
Future zoning of new/additional lot(s)
Future zoning of parent lot:
by land division:
created by land division:
19.
Covenants or restrictions will be placed on the land division area:
Yes
No
If Yes, identify covenants or restrictions:
20.
A residential building is currently located in the land division area:
Yes
No
If Yes, the building utilizes a:
Private onsite wastewater treatment system
Public sanitary sewer system
21.
22.
Public improvement construction proposal/plan will
Public improvement construction will begin on
be submitted by (mm/dd/yyyy):
(mm/dd/yyyy):
APPLICANT STATEMENT AND SIGNATURE
I, as the undersigned, am a landowner applying for a minor land division in unincorporated Rock County, or am serving as the primary
contact for said landowner. I do hereby verify that I have reviewed the ROCK COUNTY PRELIMINARY MINOR LAND DIVISION –
APPLICATION FORM INFORMATION, reviewed and completed this application form, and submitted all information as required per said
documents, and that all information is correct, accurate, and true to the best of my knowledge and belief, with all information accessible
to me. These statements are being made to induce official action on the part of Rock County, its agents, employees, and officials.
LANDOWNER/PRIMARY CONTACT SIGNATURE: ______________________________________
DATE: _____________________
Page 1 of 2
REVISED 12/2011
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