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Burnett County Subdivision Permit Application PP 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 I <br /> Owner: KG Trust Buyer: ,.d <br /> Rep: Gary Pavficekto <br /> Address: P.O. Box 455 Address: g. <br /> Siren, WI 54872 <br /> 651-247-3150 6,c <br /> Phone: Phone: cw <br /> Map 2 Original Parcel Information 1 <br /> 07-026-2-39-15-28-3 01-000-011100 & <br /> Parcel ID#: 07-426-2-39-15-28-3 01-000-011200 Section 28 Township 39 Range 1 5 �' <br /> a <br /> Original Description(or attach copy)Part of Lot 1 and Lot 2, CSM, V.22, p.109 ID <br /> in NE-SW, NW-SE, GL2 and GL3 <br /> /\. <br /> RR-1 & <br /> 7,(7-\ <br /> Current Zoning: Unzoned Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: N/A <br /> 74- <br /> ).- <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N: N/A TA <br /> ;; Farmland Preservation Y/N: N Managed Forestry Law YIN: N <br /> a <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: This CSM creates 4 new lots. <br /> Acres: 13.86 <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. Basswood & Eagle Tree Drive m <br /> Proposed access to public waters to be provided Y/N: N <br /> If yes,describe access- <br /> , .) <br /> / f ' <br /> Signature of Owner: `r g` / <br /> 0 • �i mos_ Date: 4/zz/z 2.2_ <br /> on <br /> signature of owner: vale 3 <br /> a <br /> ➢ Does parcel meet Zoning Requirements? Yes No Gk,# /3 C6, a: <br /> xr• <br /> N ➢ Does parcel require a Survey? Yes No <br /> a <br /> a <br /> . Permit application fees submitted? 0 Amount S 1110 0.° <br /> Receipt# <br /> lan <br /> 0 Reconciles with Real Property Lister Yes No Date: w <br /> -CI- <br /> DZ If not,explain: <br /> 0. <br /> n <br /> 0 <br /> a. Application•.,. pproved !enied Reason for I enial: <br /> Land Use: /� 07 Date: <br /> r /ZZ <br />