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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 lication Form Survey of Existing Parcel: $50.00/lot <br /> PP Subdivision wl Survey: $200.00+$50.00/lot <br /> Owner: Secluded Land Company Buyer: <br /> 0 <br /> Address:PO Box 10 Address: i. <br /> De Sota WI 54626 o <br /> Phone: 608-790-2796 Phone: . <br /> Original Parcel Information i <br /> Parcel ID#: 07-010-2-39-17-13-3 01-000-011000 Section 13 Townshi3p 9N Range 17W <br /> Original Description(or attach copy): NE- W D <br /> S' <br /> ea <br /> 0 <br /> C) <br /> bCurrent Zoning: A-2 Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: <br /> S <br /> Name of Water Body: N/A Shoreland Agreement/SIPS Y/N; <br /> Farmland Preservation YIN:N Managed Forestry Law YIN:N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM to divide into 4 lots <br /> Acres:40 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: O <br /> m <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> Signature of Owner:-- :_� <br /> 1--dsci.,4 Ce. tr.L c Pi y^ Date: <br /> Signature of Owner: Date: 3 '22-Z.) r <br /> > Does arcel et Zonin Re o <br /> - g <br /> P quirements. Yes No L/� # �0�/ L l�r ea <br /> SI / 'I <br /> °a D• Does parcel require a Survey? Yes No -� CS <br /> z <br /> a° > Permit application fees submitted? 0 Amount$ Il---C---(°' d� <br /> Receipt# <br /> r MIReconciles with Real Property Lister No Date: ;)-\4 - : 1 4) <br /> toa <br /> °' If not,explain: <br /> r <br /> 0 <br /> Z <br /> zo <br /> Applications;_Approved / Denied' Reason for Denial: <br /> fcf.� -2,014e___ /)14P-Z/-0V <br /> Land Useii —7i•-, 6/0r . / Date: <br />