"VERNON COUNTY ZONING PERMIT NO. _____"
MONROE COUNTY PLANNING & ZONING PERMIT NO. 14307 Cty Hwy B, C-21A . TAX PARCEL ID# Sparta, WI 54656 DATE Fax 608-269-8795 Telephone: 608-269-8736 APPLICATION FOR LAND USE PERMIT THE UNDERSIGNED HEREBY MAKES APPLICATION FOR A PERMIT TO DEVELOP FLOODPLAIN. The work to be performed, including flood protection works, is as described below and in attachments hereto. The undersigned agrees that all such work shall be done in accordance with the requirements of the County Floodplain Zoning Ordinance, Shoreland/ Wetland Zoning Ordinance and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin and the Federal Government. LANDOWNER LEGAL DESCRIPTION ADDRESS LOT# BLOCK# SUBD. OR CSM# CITY, STATE , ZIP PHONE NUMBER CITY VILLAGE TOWN NEAREST ROAD PROPOSED WORK FLOOD DISTRICT BUILDING AREA Subdivision Regional FF New Sq. Feet Filling Regional FW Addition Floor (USGS) Grading RFE (USGS) Alteration # Bedrooms Mineral removal Top of fill (USGS) Moving Date Assessed Dredging FIRM Zone Z. Permit # Ass. Cost $ Wetland S. Permit # Cost of Project$ Shoreland Sqft. Of Fill CONTRACTOR/BUILDER PERMIT ISSUED PERMIT DENIED PERMIT FEE $ 20.00 Payable to Monroe County Planning & Zoning Cert. Of Compliance Other Permits Required: REASON FOR DENIED PERMIT OWNER/AGENT SIGNATURE ZONING ADMINISTRATIOR YOU ARE RESPONSIBLE FOR COMPLYING WITH STATE AND FEDERAL LAWS CONCERNING CONSTRUCTION NEAR OR ON WETLANDS, LAKES, AND STREAMS. WETLANDS THAT ARE NOT ASSOCIATED WITH OPEN WATER CAN BE DIFFICULT TO IDENTIFY. FAILURE TO COMPLY MAY RESULT IN REMOVAL OR MODIFICATION OF CONSTRUCTION THAT VIOLATES THE LAW OR OTHER PENALTIES OR COSTS. FOR MORE INFORMATION, VISIT THE DEPARTMENT OF NATURAL RESOURCES WETLANDS IDENTIFICATION WEB PAGE www.dnr.wi.gov/wetlands/delineation.html OR CONTACT A DEPARTMENT OF NATURAL RESOURCES SERVICE CENTER. ___________________________________________ __________________________ Signature of Property Owner Date By signing this, I acknowledge that I have received this notice. Scaled site development plan required on separate page INSPECTION RECORD: Inspected by: Date: Certification of Compliance issued: Date: Sent to DNR: Date: Plans prepared by: Date: (Landowner/Land Surveyor/Engineer/Architect Comments or Conditions: