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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 .Applicv,tion Form Subdivision w/Survey: $200.00+$50.00/1ct 1 <br /> Owner: Secluded Land Company Buyer: oz <br /> eD <br /> Address: PO Box 10 Address: 3 <br /> De Sota WI 54626 <br /> 0 <br /> Phone: 608-790-2798 Phone: <br /> �2 <br /> Original Parcel Information <br /> Parcel ID#: 07-013-2-39-17-13-3 03-000-011000 Section 13 Township 39N Range 17W <br /> 0 <br /> Original Description(or attach copy): SW-SW <br /> n <br /> .= Current Zoning: RR3 Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: t <br /> 3 <br /> • <br /> z, Name of Water Body: N/A Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation YIN: N Managed Forestry Law Y/N:N 1— <br /> New Parcel Information t. <br /> Proposed New Legal Description and Parcel Size: 2 CSM`S to divide into 7 lots <br /> Acres:40 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: G <br /> to <br /> r. <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: U <br /> Signature of Owner: c..l-_w0:nj &4 Cor 1.-/-c- ,7; Date: G <br /> Signature of Owner:/40..ce-r,74� Date: 3 Z" ZJ o <br /> 2 <br /> �L� .a <br /> Com' a <br /> > Does parcel meetirements. Yes No 60 9 Z „ <br /> NY Does parcel require a Survey? Yes No 3 c5/44_s <br /> aO <br /> cm <br /> Permit application fees submitted? 0 Amount$ •/Scor O Receipt# <br /> r, FI Reconciles with Real Property Lister ® No Date: . -'--,3.( <br /> m <br /> °' If not,explain: <br /> o <br /> 0 <br /> a <br /> Qt <br /> Applicatio pproved Denied Reason for Denial: <br /> Land Use: - -- - _ CC' fe Zee.. Date: <br />