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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+$50.00/lot <br /> Owner: Toni Koziak Buyer: ,ti <br /> 1333 Bass Lake Rd <br /> Address: Address: w <br /> Hudson WI 54016 V <br /> 0 <br /> Phone: 715-716-0917 Phone: CD <br /> Orisinal Parcel Information <br /> ) <br /> 07-012-2-40-15-10-5 15-128-306000 ?•1 <br /> Parcel ID#: 07-012-2-40-15-10-5 15-128-305000 Section 10 Township 40N Range 15W <br /> Original Description(or attach copy): Deerpath Add to Voyager Village Lts 296&297 0� <br /> n <br /> PUD N N - , <br /> .o Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: <br /> C <br /> eb a Name of Water Body: N/A Shoreland AgreementlSIPS Y/N: )* ,. <br /> aN <br /> Farmland Preservation Y/N: Managed Forestry Law YIN: N <br /> New Parcel Information <br /> ?"- <br /> Proposed New Legal Description and Parcel Size: CSM combine lots <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: t7 <br /> a <br /> A <br /> Proposed access to public waters to be provided Y/N: �•• <br /> If yes,describe accessIPX <br /> 0 <br /> FaVAIifig <br /> et Date: 1/7/2-2 <br /> Signature of Owner: Date: a <br /> 6 <br /> C <br /> > Does parcel meet Zoning Requirements? Yes No 4-.4 ‘o 6 3 ? <br /> > Does parcel require a Survey? Yes No <br /> aaD De 1 <br /> T. <br /> > Permit application fees submitted?LL �0 Amount$ _^Receipt# <br /> m Reconciles wesith Real Property Lister No Date: 8/4/(QD ,tv� <br /> If not,explain: <br /> 7:1a 0i <br /> a <br /> Application: •pproved I-Denied Reason for Denial: <br /> O�� <br /> Land Use: ( �� .r.----- 0e' Z4)Z-Z, Date: <br />