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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivisionw/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survey: $200.00+$50.00/lot <br /> owner: Secluded Land Company Buyer: <br /> ro <br /> R <br /> Address:FU Box 10 <br /> t. <br /> Address: B <br /> De Sota WI 54626 0 <br /> 608-790-2798 <br /> Phone: Phone: <br /> Original Parcel Information 4 <br /> Parcel ID#: 07-016-2-39-17-14-4 01-000-011000 section Township 39N Range 17W <br /> Q <br /> Original Description(or attach copy): <br /> NE-SE a <br /> A <br /> t> <br /> r\ <br /> ;;- i <br /> nes Current Zoning: A-2 Floodplain YIN: N Wetlands Y/N: N Lake/River Class: <br /> Is <br /> toName of Water Body: N/A Shoreland Agreement/SIPS Y/N; <br /> Farmland Preservation YIN:N Managed Forestry Law Y/N:N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM to divide into 4 lots <br /> Acres:40 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: d <br /> m <br /> Proposed access to public waters to be provided Y/N: `•° <br /> If yes,describe access: <br /> Signature of Owner: . .EZ-1-1A-101s4 1.o Co- 1_-1-C 6 ' Date: <br /> Signature of Owner: sDate: Y.--Z-2-.--Z-2--2-J cANOMIIIIPOW <br /> B <br /> > Does parcel - .Hing Requirements? Yes No m <br /> 0 > Does parcel require a Survey? Yes No <br /> R <br /> Q° A Permit application fees submitted? 0 Amount$ Receipt# <br /> ®Reconciles with Real Property Lister ( W) No Date:b/tdat 6 <br /> a. If not,explain: <br /> n <br /> n <br /> O <br /> CY <br /> h <br /> Application pproved / enied Reason for Denial: <br /> Land Use: /Vzo 7i�Date: <br /> re zone /YP- ZI-D 3 <br />