Application is hereby made to the Planning Commission for a Special Use Permit pursuant to the provisions of Sec. 4.23 and/or Sec. 4.24 of Port Sheldon Township Zoning Ordinance #32.

Name of Applicant_______________________________________phone___________________________

Mailing address of applicant________________________________________________________________

Street Address of property in question________________________________________________________

Parcel Number of property in question________________________________________________________

Zone District Classification of property________________________________________________________

Applicant's interest in property______________________________________________________________

Name/Address of property owner ___________________________________________________________

Describe request in detail__________________________________________________________________

_____________________________________________________________________________________
If there has been a previous request involving the removal of natural resources or creation of a pond on
premises state the date of filing, nature of the request and action taken by the Planning Commission.
_____________________________________________________________________________________

Pond applications must include a site plan showing the proposed pond in relation to the property lines, and any buildings located on the property.

Size of Proposed Pond____________________________________________________________________

The following must be submitted for removal and processing of topsoil, stone, rock, sand, gravel, lime or other soil or mineral resources when authorized as a Special Use by the Planning Commission:

1. Type of natural resources requested to be removed___________________________________________

2. Indicate the size of the property from which the material is to be removed__________________________

3. Indicate the amount of  material requested to be removed______________________________________

4. Indicate the purpose of such removal_____________________________________________________

5. Indicate the effect of such removal on adjoining property_______________________________________

6. Indicate the effect of such removal in causing a safety hazard, creating erosion problems, or altering the groundwater table.___________________________________________________________________

7. Indicate the potential for such removal to cause the creation of sand blows, stagnant water pools, or swampy areas_____________________________________________________________________________

8. Indicate the effect of such removal on the environment and the natural topography, and the potential           
   destruction of any natural resource_______________________________________________________ _________________________________________________________________________________

9. Indicate the potential traffic congestion and problems because of trucks or other vehicles or means  utilized to haul and transport the materials removed___________________________________________________ _________________________________________________________________________________

Signature of Applicant_____________________________________________________________________