Application For Land Division/ Rezoning Form

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Application for Land Division/ Rezoning for the Town of Lake Mills
Pursuant Town Ord. 5-4 & 5-14
This petition, made under and pursuant to the Town of Lake Mills ordinance 5-4 of the Town of Lake
Mills Ordinances, requests the Lake Mills Town Board to (Parcel split/ amend zoning) of the parcel
described below:
Name of Petitioner:_____________________________________________________________________
Petitioner's address: ____________________________________________________________________
Phone #'s Home__________________________Work_________________________________________
Parcel #: 018-0713-_____________- ____________ Parent Parcel Size (Acres) _____________________
Present Use: __________________________________________________________________________
IF rezoning change of zoning classification from _______________________district to ______________
IF parcel split/rezone describe intent and description of parcel to be dividedand/or rezoned:
_____________________________________________________________________________________
_____________________________________________________________________________________
Property Owner(s) (If different from above)
Name: _______________________________Name: __________________________________________
Address: _______________________________Address: _______________________________________
Phone: ________________________________Phone: ________________________________________
Submit Preliminary Certified Survey delineating proposed land division, reasons for rezoning, type of use proposed and
structures needed, land modifications necessary, etc. (You may use additional pages, if needed). Soils reports by certified soil
tester and a final certified survey map are required, Fees are nonrefundable and must accompany petition. Check with Jefferson
Submit petition
County Zoning and with the City of Lake Mills for administrative and or buidling permit requirements.
and fees Ten days prior to next meeting, to:
Town of Lake Mills, 1111 S. Main St. Lake Mills, WI 53551.
Fees:
Certified Survey Map Application/Rezone requests $100.00 (1 to 2 lots)
Condominium Plat- $500.00, + $100/unit
Preliminary Plat- $500.00, +$100/lot (3 or more lots)
Final Plat- $100.00, + $10/lot (3 or more lots)
Re-plat- $500.00, + $100/lot (3 or more lots)
Variance/Conditional Use- $100.00
Farm Consolidation Land Divisions- $100.00
In lieu of Park Fee-for all new buildable parcel splits-$2,000.00/dwelling unit
Petitioner -understands the above fees and agrees to payment of the required fees:
Signature: ________________________________________________________ Date: ____________
AS PETITIONER, I UNDERSTAND THAT I MUST APPEAR BEFORE THE PLANNING COMMITTEE PRIOR TO THE
TOWN BOARD'S MEETING, I UNDERSTAND THAT I MUST ALSO ATTEND THE TOWN BOARD'S MEETING OR
SEND AN AGENT TO REPRESENT ME.
Signature: ________________________________________________________ Date: ____________
AS PETITIONER, I understand that the Planning Committee and Town Board may enter upon my property for inspection of
any and all rezoning/parcel split requests. AS PETITIONER, I understand that the Planning Committee will be notifying
surrounding property owners of the request.
Signature: __________________________________________________________ Date: ____________
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
FOR OFFICE USE ONLY:Date application was received _____ Paid application fee on: ____Check #______ Amount: ____
TOWN CHAIRPERSON ______________________________________ DATE __________________
_________APPROVED
____________DENIED
Date town board decision was sent to Jefferson County: _________ Date a final copy of petition was sent to applicant: ______

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