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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form or MapReview Form Subdivision w/o Survey: $50.00 <br /> PP Survey of Existing Parcel: $50.00/lot <br /> Subdivision w)Survey: $200.00+$50.00/lot <br /> Owner: Mike Henricksen Buyer: <br /> Address: 3659 STATE RD 70 Address: 2 <br /> Siren WI 54872 z <br /> ZO <br /> Phone: 715-349-2987 Phone: N <br /> N <br /> Original Parcel Information <br /> Parcel ID#: 018333407400 Section 34 Township 39 Range 16 C <br /> a <br /> a <br /> Original Description(or attach copy):That part of Gov. Lot 1 , Section 34, lying south , <br /> of STH 70. 3 <br /> n . <br /> T <br /> RR-1 NI/-. P <br /> Current Zoning: Floodplain Y/N: Y Wetlands YIN: N Lake/River Class: <br /> Clam Lake <br /> .a Name of Water Body: Shoreland Agreement/SIPS Y/N; N <br /> Farmland Preservation Y/N: NN Forestry Law Y/N:a <br /> N <br /> a <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: This CSM divides the property into two lots <br /> 1/1 <br /> Acres: 3.66± and 1.30± Acres <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Access to STH 70 as shown on CSM a <br /> Proposed access to public road: <br /> OQ <br /> Proposed access to public waters to be provided Y/N: N <br /> s <br /> If yes,describe access: 1.,-, <br /> Signature of Owner: NI' C(AP q Pp f I�a Ami Da 11 <br /> signature of towner: I$ S 1 yK4 Ai Pt-- vale: E <br /> F., <br /> Does parcel meet Zoning Req nems? No -SDI <br /> S <br /> Does parcel require a Survey? Yes No <br /> B' > Permit application fees submitted? 0 Amount$ Receipt# tC- <br /> r W <br /> 0 Reconciles with Real Property Lister Yes No Date: 'C <br /> a If not,explain: <br /> a <br /> n. <br /> r, <br /> a <br /> a <br /> a, Application: •pproved / i enied Reason for Denial: <br /> Land Use: Se.es_. Gip- az. - is Date: <br /> y/A044,--: •—•"'"----------- $- Z4 ZoaZ <br />