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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/tot <br /> and/or Pre-Application Form Subdivisioaw/Survey: $20000+$50.QC"tu: <br /> Owner: Lori Gibson Buyer: <br /> ro <br /> Address: N8543 Lakeshore Dr Address: 0 <br /> .. <br /> Fond Du Lac WI 54937 <br /> a <br /> C <br /> Phone:. Phone: tr, <br /> Original Parcel Information <br /> 07-012-2-40-15-27-5 05-001-015000 <br /> Parcel ID#: 07-012-2-40-15-27-5 05-001-016000 Section 27 Township `ON Range 15W <br /> Original Description(or attach copy): NW-SE&GL 1 <br /> •o Current zoning: RR1 &3 Floodplain Y/N Y Wetlands Y/N: Y Lake/River Class: <br /> n' Name of Water Body: Green Lake Shoreland Agreement/SIPS Y/N; <br /> a <br /> R , <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> New Parcel Information D <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Q <br /> g <br /> Proposed access to public waters to be provided Y/N: i�C`S <br /> If yes,describe access: ;� <br /> f^ Q` <br /> Signature of Owner: r [[ - 1] !.,�_" Date: G; '/ ' Lg...., 4., <br /> Signature ofDate: c <br /> Owner: <br /> e <br /> Ys <br /> Does parcel meet Zoning Requirements? Yes Na <br /> o ga3 <br /> c ➢ Does parcel require a Survey? Yes No -e <br /> se <br /> > Permit application fees submitted? D Amount$ 3KV/ Receipt# <br /> IS <br /> r 0 Reconciles with Real Property Lister Yes No Date: V1 <br /> a <br /> If not,explain: N <br /> 0 <br /> t..11 <br /> ut <br /> Applicati :(Approved / enied Reason forDeniaL: 1- <br /> Land Use: Date: 0-Vaar? 4 <br />