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Y <br /> Burnett County Subdivision Permit Application FcrN(must accompany farm): <br /> and/or Pre-Application Form or Map Review Form ! Sun`lo}tofExisting"p�«e,: $50.00 <br /> so.o;,at <br /> subdivision w Survt 5200.00-+S50,0(1101 <br /> Daniel Chelmo <br /> Owner: Buyer: <br /> - <br /> Address: P 0 BOX 397 Address: <br /> WAUTOMA WI 54982 i - <br /> :g) <br /> CA <br /> Phone: Phone: . <br /> Original Parcel information <br /> Parcel ID#: 07-020-2-40-16-33-5 05-004-013002 Section 33 Township 40 Range 16 s <br /> Original Description(or attach copy): GL4 EX: N 40 RDS. CSMS V1 P261 V24 <br /> P158 & V24 P270 C7f <br /> 5't <br /> RR-1N/A <br /> , , <br /> Current Zoning: Floodplain YIN: Wetlands YIN: N Lake/River Class: <br /> .o Name of Water Body: Devils Lake Shoreland Agreement/SIPS Y/N: N <br /> .a t <br /> la <br /> Farmland Preservation YIN: N Managed Forestry Law Y/N: N ~ <br /> New Parcel Informal-10u IP <br /> Proposed New Legal Description and Parcel Size: "` A 1`' used to creat4 new lots <br /> in Gov. Lot 4. <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road• 66' private easement to CM A o <br /> n <br /> Proposed access to public waters to be provided Y/N: N <br /> If yes,describe access: <br /> — e.---- <br /> Signature <br /> Signature of Owner: Date: t'6 -2., - 2,02,1 e <br /> z. <br /> signature of owner: nate: <br /> Is <br /> .L <br /> Does parcel meet Zoning Requirements? Yes C� " 1/z 7 <br /> ,t <br /> N; % Does parcel require a Survey? Yes No <br /> A. <br /> '••• Permit application_fees submitted? 0 Amount S Vti9II7'-- Receipt# <br /> ifs <br /> FO <br /> ❑ Reconciles with Real Property Lister Yes No Date <br /> eiIf not,explain: <br /> Z <br /> et <br /> r <br /> a Application Approved / enied Reason for Denial: <br /> Land Use: 7/677-0 zt Date: <br />