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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision win Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/tot <br /> and/or Pre-Application Form Subdivision wi Survey: $200.00+$50.00/tot <br /> Owner <br /> Owner: Jay&Deanna Keppen David&Linda Hughes Rev Trust <br /> WON <br /> Address: 1117 15th St Address: 5319 Mail Rd 3 <br /> Barron WI 54812 p r� —Danbury WI 54830 01 <br /> C. <br /> Phone: t7 1 5` C"3 7 " 5r-�! l 7 Phone: 1 1 cg(1?C-4 J .� <br /> Original Parcel Information <br /> 07-012-2-40-15-18-5 05-008-01100Q18 40N 15W <br /> Parcel ID#: Township ownship Range <br /> Original Description(or attach copy): GL 8 O <br /> ft <br /> Current Zoni R1/RR2 Floodplain YIN: Y Wetlands Y/N: Y Lake/River Class: <br /> m Name of Water Body: Ham Lake f- <br /> F. <br /> Shoreland Agreement/SIPS YIN: "p <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM <br /> u, <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> a <br /> Proposed access to public waters to be provided Y/N: :?�, <br /> If yes,describe access: �rl�rllS 1-' - t s Date: Q a`ate`0,t�gq N <br /> �Il�li <br /> IIIIIIIIIIIIIIIIIIIIIII li <br /> C#'cs- 0 * / ru".— Date: t' a` - p3i 2 " (:),.a_. .____ c <br /> s <br /> > Does parcel meet Zoning Requirements? Yes Na n <br /> ctklvO.� 3 <br /> r ➢ Does parcel require a Survey? Yes Na <br /> a <br /> °° > Permit application fees submitted? 0 Amount$ ,O(� Receipt# p�``�, <br /> r 0 Reconciles with Real Property Lister Yes No Date: p <br /> to <br /> a ,(-) <br /> a` If not,explain: <br /> r <br /> A <br /> n <br /> 0 <br /> 0 <br /> a <br /> at <br /> App y=TAppro�Deaied Reason for Denial: <br /> Land Lice i% ,r1_,--------) // 20 2 -2— Date: <br />