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lECEOVED <br /> SRR032C21 <br /> Burnett County <br /> Land Services Department <br /> Ci-‘t (e 04t(rte $a50 <br /> 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-Application Form Subdivision w/Survey: $200.00+$50.00/lot <br /> Owner: Thomas Derrick Buyer: „d <br /> ee <br /> Address: 1412 160th Ave Address: <br /> New Richmond WI 54017 , <br /> :4 <br /> c <br /> Phone: Phone: M <br /> ›, Original Parcel Information <br /> 07-012-2-40-15-21-1 04 000-011000 21 1 <br /> Parcel ID#: Section Townshi 4p ON Range 15W il- <br /> Original Description(or attach copy): SE-NE Ex CSM V12 P203 � <br /> ro <br /> / D--- <br /> .o Current Zoning: .�Floodplain Y/N: N Wetlands Y/N: Y Lake/River Class: <br /> b CN <br /> a Name of Water Body: NSA Shoreland Agreement/SIPS Y/N: N <br /> r+ Farmland Preservation Y/N:N Managed Forestry Law Y/N:N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM to divide into 2 parcels 1 1 <br /> A- <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: t7 <br /> a <br /> Proposed access to public waters to be provided Y/N: n^ <br /> If yes,describe access: " ,/ <br /> Date: 0' <br /> II n <br /> Signature of Owner: f <br /> Signature of Owner: Date: c <br /> 5 <br /> ^e <br /> > Does parcel meet Zoning Requirements? Yes No <br /> e <br /> N <br /> c > Does parcel require a Survey? Yes No <br /> v V)� > Permit application fees submitted? ❑ Amount$ Receipt# <br /> J, <br /> r 51 Reconciles with Real Property Lister ® No Date: 9/$(c2' <br /> 0 <br /> Q' If not,explain: <br /> r <br /> n <br /> n <br /> 0 <br /> 0s <br /> ty <br /> w <br /> Applicatio t Approved Denied Reason for Denial: <br /> .7 <br /> Land Use: ��a.... J/ / P/ZO L/ Date: <br /> e. <br /> r - ' /09P— 2f— //, ins / rc (q rP-�-°,,,a <br /> RA-3. <br />