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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+$50.00/lot <br /> Owner: Keith Peterson Buyer: ,t <br /> A <br /> Address: 1225 Racine Dr Address: <br /> Spooner WI 54801 0 <br /> 612-240-2620 <br /> Phone: Phone: <br /> Original Parcel Information �T <br /> 13 TownshiParcel ID#: 07-028-2-40-14-13-5 05-002-012001 Section 40N Range 14W U7 <br /> Original Description(or attach copy): S 11.56a Gov Lot 2 Ex N 400' of TH prt Vac Racine Dr o <br /> CD <br /> .o Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: N Lake/River Class: <br /> Middle McKenzie Lake <br /> m Name of Water Body: Shoreland Agreement/SIPS Y/N; <br /> a <br /> Farmland Preservation YIN: N Managed Forestry Law Y/N:N <br /> New Parcel Information 9 <br /> J <br /> Proposed New Legal Description and Parcel Size: CSM divide into 3 parcels <br /> . Acres:tirlia7 4.O'8 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.)__ <br /> Proposed access to public road: C <br /> m <br /> 2 <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: ,� <br /> Signature of Owner: Date: 3"5.,-5 Z-( <br /> Signature of Owner: Date: o <br /> a <br /> ,°> Does parcel meet Zoning Requirements? Yes No o 35 ' a <br /> CD <br /> a > Does parcel require a Survey? Yes No <br /> E. <br /> C d <br /> Q° > Permit application fees submitted? 0 Amount$ 3.�♦O� Receipt# 3:3 ' <br /> m IS Reconciles with Real Property Lister Yes No Date: 5-a5-ami 6" <br /> 0. If not,explain: <br /> n W <br /> a <br /> a. <br /> O <br /> Application:, ved-Denied Reason for Denial: J <br /> r Date: <br /> Land Use: � (• e -- _ ', >t,";_ � <br />