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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form or Map Review Form Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Subdivision w/Survey: $200.00+$50.00/lot <br /> Owner: KG Trust Buyer: "v <br /> et <br /> Rep: Gary Pavlicek <br /> Address: P.O. Box 155 Address: ;: <br /> Z <br /> Siren, WI 54872 0t./ <br /> C <br /> 651-247-3150 vs <br /> Phone: Phone: <br /> Map 1 Original Parcel Information <br /> V <br /> Parcel ID#: 07-026-2-39-15-28-3 01-000-011100 Section 28 Township 39 Range 15 0 <br /> Original Description(or attach copy)?art of Lot 1 , CSM, V.22, p.109 <br /> '', '\1E-SW, NW-SE 7C <br /> RR-1 & <br /> Current Zoning: Unzoned Floodplain Y/N: N Wetlands YIN: N Lake/River Class: N/Aid <br /> -a Name of Water Body: Shoreland Agreement/SIPS YIN: N/A <br /> at <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> 0 <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: This CSM creates 4 new lots. <br /> Acres: 11.57 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Private Road Access: S. Bass=,-.-d & Eagle Tree Drive m <br /> It <br /> Proposed access to public waters to be provided YIN: N <br /> If yes,describe access: 14 <br /> Signature of Owner: 0 _ O _ i_ ^/ , . Date: 4 '/ 2- <br /> 0 <br /> signature of owner: Date: 9 <br /> 10 <br /> 0 <br /> Does parcel meet Zoning Requirements? Yes 2Vo c �i l 3 S& <br /> N > Does parcel require a Survey? Yes No <br /> ez <br /> d <br /> Permit application fees submitted? 0 Amount$ 4 0 D .0i Receipt# <br /> IQ <br /> 0 Reconciles with Real Property Lister Yes No Date: dg <br /> fa If not,explain: <br /> a <br /> a <br /> 7i <br /> FS <br /> 0 <br /> o. Applicati I . Approved / I . ied Reason for Denial: <br /> Land Use: 0 Z7 2 Date: <br />