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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 or Map Review Form Subdivision w/Survev: 5200.00+$50.00/lot <br /> Owner: Charles R.Johnson Buyer: James Melin 1 <br /> Address: 22095 County Road Y Address: 21071 Melo Drive <br /> Grantsburg WI 54840 Grantsburg,WI 54840 <br /> Phone: C <br /> (L1- 488-2200 Phone: (715)488-2295 7 <br /> e� <br /> OriEinal Parcel Information <br /> Parcel ID#: See Attached Addendum A Section 05 Township 37N Range 18W <br /> Original Description(or attach copy): See Attached Addendum A <br /> Current Zoning: Floodplain Y/N: N Wetlands Y 1 i Lake/River Class: <br /> Y <br /> 10 <br /> Name of Water Body: Shoreland A Bement/SIPS Y/N: <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: See Attached Addendum B <br /> d <br /> A <br /> Acres: 15 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: County Road Y <br /> Proposed access to public waters to be provided Y/N: N/A <br /> z <br /> If yes,describe access: <br /> Signature of Owner: Date: /5— <br /> Signature of Owner: / Date: <br /> ➢ Does parcel meet Zoning Requirements? ( Yes ��N-o—� <br /> N ➢ Does parcel require a Survey? Yes _/ No/ <br /> a �� <br /> ;i�' Permit application fees submitted? Amount$ _DU, Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> r <br /> If not,explain: <br /> a <br /> 77 <br /> 0 <br /> -e <br /> a Application: Approved Denied Reason for Denial: <br /> H <br /> Land U��s..//e: / Date: <br /> JP qct b 5747// q+ r /{ -ID <br />