For Instructions & How to Submit - Click Here
Date:
Tax Key #
Owners Name:
Mailing Address:
Phone - Home: Work:
Property Location's Address:
Legal Description: Section Town/City/Village
Lot Block Subdivision CSM#
Project for: [check appropriate boxes]
Commercial
Residential Detached accessory
New Existing Other
Brief description of project:
Following items must be submitted: Full legal description of the property, map, drawn to scale or showing
dimensions, including boundaries and dimensions of the property, location and distances from existing and
proposed buildings and/or grading/filling/excavating to lot lines, location and distances from private onsite waste-
water treatment systems and wells to lot lines and buildings, and an arrow indicating north. If soil borings are
required, the system may be condemned as a result of soil conditions observed.
Please allow a minimum of 24 hours for review. Submit Documents to: PermitAR@co.washington.wi.us
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(For Department Use - Do Not Fill In Below This Line)
Permits Required Yes No County Permit Issued Date Issued
Erosion Control - Chapter 238 No.
- Disturbs > 4,000 Sq. Ft.
Stormwater Management - Chapter 238 No.
- Increases Impervious > 20,000 Sq. Ft.
Floodplain - Chapter 275 No.
Shoreland/Wetland - Chapter 275 No.
Sanitary - Chapter 190
No.
Authorized Signature
Remarks:
Form 1642 (Rev. 01/06/2021)
copy to Owner copy for Department
INCLUDING COUNTY HIGHWAY DEPARTMENT, TOWN, VILLAGE, CITY,
STATE DEPARTMENT OF NATURAL RESOURCES, AND/OR ARMY CORPS. OF ENGINEERS.
Washington County
Public Agency Center - 333 East Washington Street, Suite 2300, P.O. Box 2003, West Bend, WI 53095-2003
Phone: 262.335.4445 Toll Free: 800.616.0446 (Wisconsin Only) FAX: 262.335.6868
PERMIT APPLICATION REVIEW FORM
*NOTICE TO APPLICANT: PERMITS MAY ALSO BE REQUIRED FROM OTHER AGENCIES
Email: ___________________________________________________
Planning and Parks Department - Land Resources Division
click to sign
signature
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