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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/Survev: $200.00+$50.00/lot <br /> Owner: Mark Tyberg Buyer: .d <br /> A <br /> Address: 25295 Wellman Rd Address: 9 <br /> z <br /> Grantsburg, WI 54840 ° <br /> Phone: (715)689-2208 Phone: <br /> Orieinal Parcel Information W <br /> Q0 <br /> Parcel ID#: Legacy ID 040352501900/DNR 040352501700 Section 25 Townshi 3' 9 Range 18 C <br /> Original Description(or attach copy): N 300'of the NE quarter of SW quarter, section 25,T39N, R18W <br /> Burnett County,WI <br /> Current Zoning: RR3, F1 Floodplain YIN: No Wetlands Y/N: Some Lake/River Class: N/A <br /> V <br /> Name of Water Body: N/A Shoreland Agreement/SIPS Y/N: No <br /> 0 <br /> Farmland Preservation Y/N: No Managed Forestry Law Y/N: No <br /> New Parcel Information l ,501 , oqS ,3aq-3a7 1,U <br /> Proposed New Legal Description and Parcel Size: One new lot by certified survey map new lot by certified survey map includingparts of <br /> both parcels noted above (see attached preliminary map). <br /> Acres: 9.1 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: N/A <br /> Proposed access to public waters to be provided Y/N: No <br /> If yes,describe access: <br /> Signature of Owner: +k� 7 Date: 1/13/2016 <br /> Signature of Owner: Date: 3 <br /> 'v <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No w4 •�'µ� �� {t'Ky GSWI <br /> ➢ Does parcel require a Survey? Yes No <br /> 5 <br /> °Q D Permit application fees submitted? ❑ Amount$ 919 Receipt# <br /> r. ❑Reconciles with Real Property Lister Yes No Date: <br /> ° <br /> 0 <br /> ° If not,explain: <br /> n <br /> JAN 13 2ot5 <br /> O <br /> 1 <br /> a <br /> y <br /> Applicata Approved provedl Reason for Denial: <br /> Land UDate: <br />