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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survey: $200.00+$50.00/lot <br /> Owner: Keith Peterson Buyer: .z <br /> n <br /> Address: 1225 Racine Dr Address: LI <br /> �: <br /> Spooner WI 54801 <br /> 0 <br /> cla <br /> Phone: 612-240-2620 Phone: <br /> Original Parcel Information <br /> 07-028-2-40-14-13-5 05-002-012001 13 40N 14W <br /> Parcel ID#: Section Township Range <br /> O <br /> Original Description(or attach copy): S 11.56a Gov Lot 2 Ex N 400' of TH prt Vac Racine Dr <br /> .= Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: N Lake/River Class: ' <br /> oName of Water Body: Middle McKenzie Lake Shoreland Agreement/SIPS Y/N: �1 <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N T <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM divide into 3 parcels <br /> Acres:4.85 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C7 <br /> cD <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> J g <br /> Signature of Owner: 4/<'. <br /> Z[!''��a� ` J <br /> Date: ' 15-- Z/ to <br /> Signature of Owner: Date: o <br /> -o <br /> / -, <br /> Does parcel meet Zoning Requirements? Yes No j <br /> 3 <br /> N > Does parcel require a Survey? Yes No <br /> o' cid W <br /> �Q > Permit application fees submitted? 0 Amount$ 3 , Receipt# <br /> Ci <br /> r. ❑ Reconciles with Real Property Lister Yes No Date: J <br /> If not,explain: <br /> n <br /> n <br /> _o <br /> G <br /> y <br /> Applicatio • pproved 'Denied Reason for Denial: <br /> Land Use' - 3z zez/ Date: <br />