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Burnett County Subdivision Permit Application Fees (must accompany form): <br />and/or Pre -Application Form or Ma Review Form Subdivision w/o Survey: $50.00 <br />pp 1� Survey of Existing Parcel: $50.00/lot <br />Y <br />Owner: <br />Larry & Diane Tewalt et. al. Buyer: <br />Subdivision w/ Survev: 5200.00 + $50.00/lot <br />Jerome Tewalt et. al. F�_] <br />Address: 7791 Tewalt Road Address: P.O. Box 16 <br />Siren, WI 54872 Siren, WI 54872 <br />715-349-5217 <br />Phone: <br />Phone: <br />Original Parcel Information <br />030 2320 01700, 030 2320 01900, 20 <br />Parcel ID #: 030 2320 02100, 030 2320 02200, Section <br />Original Description (or attach copy): See attached Deed <br />Township 38 Range 16 <br />Current Zoning: A-2 Floodplain Y/N: N Wetlands YIN: N Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS YIN; N <br />Farmland Preservation Y/N: E Managed Forestry Law Y/N: N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: An exchange of parcels is planned to result in Larry & <br />Diane owning the West 165' of the SW'/4-SW'/4 and the West 165' of the South 610' of Gov. <br />Lot 1. This will clear up a garage encroachment. Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Existing easement to Tewalt Road <br />Proposed access to public waters to be provided Y/N: N <br />If yes, describe access: <br />Signature of Owner: N/A Date: <br />6ignature of owner: Late: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />N ➢ Does parcel require a Survey? Yes No <br />0 <br />0 <br />Permit application fees submitted? Amount $ Receipt # <br />} Reconciles with Real Property Lister Yes No Date: 1 I ,/) /77/0 <br />If not, explain: <br />a <br />�o <br />o. Application: pproved Denied Reason for Denial:' f`� <br />Land Use: Date: <br />_ Il 9 Zo/-7 NOV 8 ?_017 T� <br />EBUR ETT COUNTY <br />