Polk County District Change Application
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1
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3POLK COUNTY DISTRICT CHANGE APPLICATION
MAKE CHECKS (black ink) PAYABLE TO:
Receipt
Print Form
Erase Form
$500.00
Fee:
Polk County Zoning Department
Number
100 Polk County Plaza, Suite 130
Use "Tab" key to move between fields
Balsam Lake, WI 54810
Original signature required
715-485-9111, Mon- Fri, 8:30am-4:30pm
Property Address (Number & Street or Ave)
Mail in application with $500 fee
Incomplete applications may delay
Property
COMPLETE ALL UNSHADED AREAS
Owner ___________________________________________________
INCOMPLETE APPLICATIONS MAY BE
Make checks (black ink) payable to:
RETURNED
Mailing
PLEASE PRINT – USE BLACK INK
Address __________________________________________________
Polk County Zoning Department
RETURN ORIGINAL FORM
100 Polk County Plaza, Suite 130
City __________________________ State _______ Zip ___________
Balsam Lake, WI 54810
Email
(715) 485-9111, Mon-Fri, 8:30am-4:30pm
(optional):_________________________________________________
Phone Number:____________________________________________
Incomplete Applications May Be Returned
LEGAL DESCRIPTION OF PROPERTY – SEE TAX BILL
Enter 12-digit Parcel/Computer# -- see tax bill
Gov’t Lot
Parcel # / Computer #
Lot #
Subdivision/CSM #
___ ___ ___ - ___ ___ ___ ___ ___ - ___ ___ ___ ___
Town of ___________________________
________ ¼
________ ¼,
Sec _______
/T _______N /R _______ W
Size of Parcel
Size of proposed REZONE parcel
OR
OR
X
=
SQ FT
Acres
X
=
SQ FT
Acres
ADDITONAL INFORMATION
Previous Owner
Date Purchased Are there buildings on the
What percent of the buildings are to be
Name of Lake/Pond/River/Flowage Lake Classification
parcel? □ yes □ no
□ 1 □ 2 □ 3
rezoned?
I request a District Change/Rezone (State briefly what is being requested & why):
The applicant, as witnessed by the applicant’s signature on this application hereby attests that the information contained therein is
accurate and true. Any assistance by County staff was at the applicant’s request.
Sign Here: _____________________________________ Date: ___________ □ Cash □ Credit □ Check # _________
Signature
COMMENTS:
Office Use Only
Receipted by: ____________________________________________
Date: ________________ Fee: $____________
Letter/Minutes from
Hearing Date/Time
Land Information
County Board Meeting
County Board
Date Received
town board hearing
Committee
Date
approval
□ Yes
□ Yes □ No
approval
□ Yes □ No
Revised 1/3/2017
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Parent category: Business