DATE ___________________________________________________
APPLICATION NO. ___________________________________________________
1. NAME OF APPLICANT ___________________________________________________
ADDRESS ___________________________________________________
PHONE ___________________________________________________
2. NAME OF SURVEYOR
ADDRESS ___________________________________________________
PHONE ___________________________________________________
3. NAME OF SUBDIVISION ___________________________________________________
4. LOCATION DESCRIPTION (TAX LOT OR OTHER IDENTIFICATION)
___________________________________________________________________________________
____________________________________________________________________________________
(IN ADDITION, PLEASE ATTACH COPY OF LEGAL DESCRIPTION)
5. PROPOSED USE ___________________________________________________
6. PRESENT ZONING DISTRICT ____________________________________________________
7. PROPOSED ZONING CHANGES ___________________________________________________
8. NUMBER OF LOTS __________________________________________________ _
AREA OF TRACT _________________________________________ __________
9. DO YOU PROPOSE DEED RESTRICTIONS? YES ____ NO ____
(IF YES, PLEASE ATTACH A COPY) _______________________________________________
10. WHAT TYPE OF SEWAGE DISPOSAL DO YOU PROPOSE? ___________________________
IF AN “ON LOT” TYPE OF SEWAGE DISPOSAL IS PROPOSED, INCLUDE A LETTER FROM THE COUNTY HEALTH DEPARTMENT APPROVING SUBSURFACE SEWAGE DISPOSAL.
11. LIST ALL PROPOSED IMPROVEMENTS AND UTILITIES AND STATE YOUR INTENTION TO INSTALL OR POST A GUARANTEE PRIOR TO ACTUAL INSTALLATION.
IMPROVEMENT INSTALLATION GUARANTEE (COST)
A. ____________ _______________ ____________________
B. ____________ _______________ ____________________
C. ____________ _______________ ____________________
D. ____________ _______________ ____________________
E. ____________ _______________ ____________________
12. VARIANCES REQUESTED FROM PLAT OR DESIGN REQUIREMENTS.
SECTION NUMBER ITEM
A.__________________ _________________
B.__________________ _________________
C.__________________ _________________
D.__________________ _________________
E.__________________ _________________
13. LIST OTHER MATERIALS SUBMITTED WITH THE APPLICATION.
ITEM NO. COPIES
A. ____________________ _________________
B. ____________________ _________________
C. ____________________ _________________
D. ____________________ _________________
E. ____________________ _________________
___________________ _ _________________________________
APPLICANT SURVEYOR
*************************************************************************************
FOR OFFICIAL USE — PRELIMINARY PLAT
DATE RECEIVED ____________________________________
DATE OF MEETING OF PLANNING COMMISSION ___________
ACTION BY PLANNING COMMISSION:
(1) APPROVED: (DATE) _______________________________to proceed to final plat.
Subject to the following modifications: ___________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
Variances granted: _____________________________________________________________________
____________________________________________________________________________________
_____________________________________, OR
(2) DISAPPROVED: (DATE) ___________________________
For the following reasons: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________ ___________________
CHAIRPERSON DATE
Note: The Commission shall have 60 days after the review of this plat to approve, disapprove or approve subject to modifications, said plat, per § 153.18(B)(3).