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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/Survev: $200.00+S50.00/Int <br /> Owner: Joe Jaskolka Buyer: <br /> Address: 23916 Tollander Road Address: <br /> Siren, WI 54872 z <br /> Phone: 715-220-1721 Phone: <br /> Original Parcel Information <br /> J <br /> Parcel ID#: 006241502400 & 006241502500 Section 15 Township 38 Range 17 <br /> Original Description (or attach copy)-Lot 11 of CSM No. 737 and Lot 12 of CSM 738 <br /> Current Zoning: Floodplain Y/N: Wetlands YIN: N Lake/River Class: I <br /> o Name of Water Body: Shoreland Agreement/SIPS Y/N: N <br /> z <br /> m Farmland Preservation Y/N: Managed Forestry Law Y/N: N <br /> New Parcel Information W <br /> Proposed New Legal Description and Parcel Size: CSM merging 2 lots Into 1 lot <br /> GSm A 0-1 P, 'in <br /> Acres: 10.23 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> d <br /> Road <br /> R <br /> d <br /> ll <br /> T <br /> t <br /> access o oaner oa <br /> Proposed access to public road: Direct � <br /> Proposed access to public waters to be provided YIN: N C� <br /> If yes, describe access: <br /> Signature of Owner: N/A Date: <br /> A <br /> �tgnature of vwner: Late: ° <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> 4L <br /> N ➢ Does parcel require a Survey? Yes No <br /> 0 <br /> e <br /> Permit application fees submitted? Amount$ Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> m If not,explain: <br /> 0 <br /> a <br /> A <br /> 0 <br /> a Applicatio Approved Denied Reason for Denial: <br /> Land Use: 9 Date: BURNETT COUNTY <br />