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Fess(must susomptruy tuna <br /> Burnett County Subdivis#®n Permit Application Sttldivisionw/olluty v $50,00 <br /> Sum of-Existing Parcel: $50.00/lot <br /> and/or Pre-Application Form Siitidivisioii w/Sahel S200 00+b3U UUttta <br /> - Owner! Suprenant Trust __ Friction <br /> __ �u��eri - <br /> Address:29207 Ford Rd Address: 4700 Dale Dr <br /> Danbury WI 54830 Edina MN 55424 r <br /> th <br /> 763-370-5334 G <br /> Phone: Phone; IP <br /> ll__ <br /> Original Parcel Information 1 <br /> 07-012-2-40-15-12-1 02-000-016000 <br /> Parcel ID#:07-012-2-40-15-12-1 02-000-014000 Section 12 Township 4ON Range 15W <br /> O.. <br /> Original Description(or attach copy): NW-NE CSM V1 P220 <br /> I <br /> .a Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: Y Lake/River Class: <br /> 1:1_ <br /> Name of Water Body: Loon Lake Shoreland Agreement/SIPS Y/N: <br /> i —1, <br /> Farmland Preservation Y/N:N Managed Forestry Law YIN: N <br /> New Parcel Information E, <br /> Proposed New Legal Description and Parcel Size: CSM 2 lot divide <br /> i <br /> Acres: 1.91 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: p <br /> Proposed access to public waters to be provided Y/N: `•• <br /> If yes,describe access: <br /> 9J <br /> _/ p <br /> Signature of Owner: I„....5 % Date: fir)..,/g.-- 2, { ?%) <br /> f t <br /> Signature of Owner: Date: o <br /> a <br /> 'o <br /> y Does parcel meet Zoning Requirements? Yes No C-A- !L 0 4 „ <br /> °oo Y Does parcel require a Survey? Yes No ` �\ <br /> E. Dp 1 <br /> IQ rf <br /> T Permit application;fees submitted? 0 Amount S MC,. Receipt# Ca• <br /> y El Reconciles with Real Property Lister Yes No Date: N <br /> R i �IJ <br /> If not,explain:, <br /> o ,jtl}. <br /> 5- <br /> m <br /> Applicat'• i: •proved / I enied Reason for Denial: 11.1 <br /> / /O/Zt7 / kJ <br /> Iuand Use: Date: <br /> 5 A/ i <br /> eh1 l s�rti i/,'ts al if te)/& 4/e yr,%. g <br /> r <br /> el"64ck Vavllavtce , li< <br /> 01 AS ilt3i9P a S io /0q14`(-€13 ,/z- <br />