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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form or MapReview Form <br /> Subdivision w/o Survey: $50.00 <br /> pp Survey of Existing Parcel: $50.00/lot <br /> Subdivision w/Survey: 5200.00+550.00/lot <br /> Daniel Chelmo .� <br /> Owner: Buyer: 55 <br /> Address: P 0 BOX 397 Address: :; <br /> WAUTOMA WI 54982 0 <br /> til <br /> VP <br /> Phone: Phone: <br /> Original Parcel Information <br /> Parcel ID#: 07-018-2-39-16-04-1 03-000-011001 Section Township 39 Range 16 o <br /> a cb <br /> Original Description(or attach copy): SW NE EX CSM#4441 V24 P158 <br /> Fl <br /> Witt AR-3 N/A <br /> Current Zonin.: A-2 i 1 1 , am Y/N: glands Y/N: N Lake/River Class: <br /> -a Name of Water Body: Yellow River Shoreland Agreement/SIPS Y/N: N <br /> -a <br /> a Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> a <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: A new 12.5 acre parcel is proposed to be <br /> created described as that part of the East 550 feet of the SW'/4-NE'/4, lying south <br /> of County Higway A. Acres: 12.5 A <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Direct Access to CTH A <br /> Proposed access to public waters to be provided Y/N: N <br /> 1..> <br /> If yes,describe access: 0 <br /> N <br /> Signature of Owner: Date: OCT 0 3. 2,.:.Ll <br /> a <br /> 0 <br /> signature of owner: Late: @ <br /> Ta <br /> > Does parcel meet Zoning Requirements? Yes No IA <br /> N ➢ Does parcel require a Survey? Yes No <br /> a <br /> a <br /> > Pcroermit application fees submitted? ❑ Amount$ 'S7 d R t# OO 1 ` <br /> ...,, <br /> ® Reconciles with Real Property Lister tryg. No Date: o1�(a► r 5 <br /> 3 <br /> Q. <br /> aIf anot,explain: w S mCl <br /> a. < 3 <br /> 2 fp, <br /> eta v o w <br /> a Applicati.. . Approved 1 enied Reason for Denial: w z c C <br /> Land Use: <br /> 0/77,gaate: <br /> al <br /> 3 11 <br />