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Pond Use: ___ Water Supply ___ Recreational ___ Mining
___ Borrow Pit ___ Animal Waste ___ Wetland
___ Livestock water ___ Fire protection
Location: ___ House Lot ___ Farmstead ___ Farmland
___ Flood Plain ___ Wetland ___ Woods
Soil Type(s) from soil survey:
Pond Type: ___ Excavated ___ Embankment ___ Clay lined
Pond Size:
Length ________ Average Width ________ Surface Area ________ Depth ________
Drainage area to pond ________ Pond Capacity ________ Spillway Capacity ________
Pond overflow outlet is directed to:
TYPE OF UTILITIES ON THIS PROPERTY:
Public Sewer ____ On-Site Septic ____
Public Water ____ On-Site Well ____
The undersigned is applying for a Zoning Certificate for a Recreational Pond and certifies that
all information on this Application and Plot Plan, as well as any additional information provided, is correct.
The undersigned must be the property owner or an authorized representative of the property owner.
SIGNATURE: DATE: _____ / _____ / _____________
* FOR OFFICE USE ONLY *
Zoning ________ Flood Plain ________ Thoroughfare ROW ________ Airport Zoning ________ OS Overlay ________
Other
NOTE: If on-site septic or on-site well, approval from
Clark County Combined Health District is required.
