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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: Anthony and Marlene Bachim Buyer: <br />Address: 3301 W Provincial Lane Address: <br />Beloit, WI 53511 <br />Phone: 608-365-4292 Phone: <br />Orizinai Parcel Information <br />07-030-2-38-16-17-1 01-000-011000 <br />Parcel ID #: 07-030-2-38-16-17-1 01-000-014000 Section 17 <br />Township 38 Range 16 <br />Original Description (or attach copy): See attached <br />Current Zoning: RR1 Floodplain YIN: <br />Wetlands YIN: <br />Lake/River Classification: Name of Water Bode: <br />Shoreland Agreemt or SIPS YIN: Farmland Preservation YIN: <br />Managed Forestry Law YIN: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Proposed CSM <br />Koch will be the owner of Lots 1 and 2 ---- Lot 3 will remain <br />with current owners <br />Lot 1 - 1.07ce, Lot 2 - 2.72ac, Lot 3 - 6.94oc <br />Acres: 10.73ac <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: County Road B <br />Proposed access to public waters to be provided YIN: <br />If ves. describe access: <br />Signature of Owner: ' '2 . i.I ,ry .0 N'1t Date• a01 W <br />:1 <br />Signature of Owner: h <br />h Ifri-e Date: _ a - a 3 - a o I R <br />Does parcel meet Zoning Requirements? Yes No <br />N <br />0 <br />v Does parcel require a Survey? Yes No <br />as <br />> Permit application fees submitted? ❑ Amount $, Receipt # <br />m ❑ Reconciles with Real Property Lister Yes No Date: <br />a <br />a <br />If not, explain: <br />n <br />0 <br />to <br />y ' <br />Land Us <br />Reason for <br />3 L.3 <br />Q <br />00 <br />