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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application SubdivisionwloSurvev: $50.00 <br /> Surveyof Existing Parcel: $50.00Aot <br /> and/or Pre-Application Form Subdivision w/Survey: S200.004 SSO.00Aof <br /> Owner: Richard Harder Buyer: John KubiChek/Ted & Memo a Priam .y <br /> Address: 76995 Fast Benoit Rd. _ _ Address: c/o Ted Priem <br /> 1105 Pine Street c <br /> Spooner WI 54801 St Croix Falls WI 54024 % <br /> U <br /> Phone: 715-6'15-4723 Phone: 239-693-5895 L <br /> J <br /> Original Parcel Information <br /> Parcel ID#:07-024-2-39-14-03-4 04-000-01100&ction 3 Township 39N Range 14W <br /> O <br /> f <br /> Original Description(or attach copy): SE1/4 of '.;Fl /4 Sprti nn 4 TOremsh j la 39 Ngrth' <br /> Range 14 West <br /> a Current Zoning Floodplain YIN: N Wetlands YIN: N Lake/River Class: N <br /> w Name of Water Body: None Shoreland Agreement/SIPS YIN, N <br /> Farmland Preservation YIN: N Managed Forestry Law YIN: N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: North 20 acre ( nom;?_E1 14 SE /4) <br /> to be sold to John Kubichek South 20 acres (ql /2 SF1 /4 SEI/4) to hp QnIrj <br /> to Ted and Theresa Priem. Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: public road at Southeast corner of forty. d <br /> A <br /> Proposed access to public waters to be provided Y/N: N <br /> If yes,describe access: <br /> 3 )Signature of Owner: Date: <br /> Signature of Owner: Date: O <br /> �J <br /> Y Does parcel meet Zoning Requirements? �' }'es No J (� 3'15'1( =0 <br /> Does parcel require a Survey? Iles �No <br /> R} <br /> °q D Permit application fees submitted? ❑ Amount$ 0 Q Receipt# <br /> r Reconciles with Real Property Lister Yes No Date: L ' .i• O� o <br /> a <br /> p If not,explain: t <br /> n <br /> a O S <br /> G <br /> Application: Approved / Denied Reason for Denial: _ <br /> 0 <br /> i .,..a n.o. _ Date: 3.i� 7� <br />