Date Number Required Fee $200.00
Present Owner Address Phone
Future Owner Address Phone
Surveyor Address Phone
Applicant Address Phone
List All Adjoining Landowners:
Address Phone
Address Phone
Address Phone
Location: ¼ ¼ Section Number Tax Parcel Number
Present Use of Land
Intended (Proposed) Use of Land
Intended Time Table for Development
Total Size of Property (all parcels within division)

Please Attach a sketched map of the proposal at a scale of 1”=200 feet. Identify all contiguously owned land in sketch. Include all of the following information on the map:
1. North arrow, data, scale, and reference to section corner.
2. Approximate dimensions of the parcels and easements.
3. The locations and type of existing and proposed buildings, water wells, sewerage systems, watercourses, drainage ditches and other pertinent features.
4. The location of the “Limits of Disturbance” (LOD) lines. The LOD shall indicate the specific areas of a site within which the developed project may be constructed and within which development activity shall be contained.
5. Setback or building lines required.
6. The uses of the adjacent property, existing and proposed roads within 1000 feet, existing driveways within 1000 feet, easements of record, public access to navigable waters, dedicated areas and utilities.

Tentative Approval: The Board may grant tentative approval based on the Letter of Intent and sketch map pending submission of the Certified Survey Map. Tentative approval shall assure final approval if the certified survey submitted within six months is substantially the same plan and all requirements for division are met. A $250.00 park fee must also be paid when submitting this letter of intent. Park Fee will be refunded if Letter of Intent is denied.

Towns Recommendation

Approve ________ Deny _________ No Recommendation_________

Date of Recommendation_____________________________________

Comments:

Plan Commission Representative Town Board Chairman