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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> and/or Pre-A lieation Form Survey of Existing Parcel: $50.00/lot <br /> PP Subdivision w/Survey: $200.00+$50.00/lot <br /> -- Owner: James Berg Buyer: <br /> r* <br /> O/ <br /> 6613 Bushey Rd Address: g. <br /> Danbury WI 54830 <br /> Phone: Phone: Pj <br /> Original Parcel Information <br /> k <br /> Parcel ID#: 07-036-2-40-17-03-4 01-000-011000 Section 03 Township 40 Range 17 <br /> GI <br /> CP <br /> Original Description(or attach copy): NE-SE a <br /> et <br /> b Current Zoning: A2 Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: <br /> o Name of Water Body: NSA Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: Noil <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: Lot 1 CSM <br /> Acres:6.70 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: d <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> Signature of Owner: w �% Date: c. 2-.. ZC_ 7,21/ <br /> (-77 <br /> Signature of Owner/ Date: n <br /> 0 <br /> 5 <br /> ➢ Does parcel meet Zoning Requirements? Yes No Lk ,7 , C <br /> � 66 <br /> N <br /> E D Does parcel require a Survey? Yes No <br /> °rei > Permit application fees submitted? ❑ Amount$ 2P, Receipt# .. <br /> th <br /> 1 <br /> 0 Reconciles with Real Property Lister Yes No Date: 1 <br /> o <br /> °' If not,explain: <br /> e, <br />