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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: 550.00 <br />and/or Pre -A lication Form Survey Existing Parcel: 0.00 lot <br />PP Subdivision w/ Survev: 52000.00 + $50.00/lot <br />Owner: Converge Great Lakes <br />Address: 5315 Wall St Ste 170 <br />Madison, WI 53718 <br />Phone: (608)244-5000 <br />Buyer: <br />Matthew Jensen <br />Address: 8762 Dunkirk Ct NE <br />Phone: <br />Blaine, MN 55449 <br />Original Parcel Information <br />07-042-2-38-18-34-5 05-003-011001 34 <br />Parcel ID #: 07-042-2-38-18-33-4-04-000-011001 Section33--Townshi 3� 8 Range 18 <br />Original Description (or attach copy): PCL Gov Lot 3 & E1/2 SE SE, E 2 Rds W 1/2 SE SE <br />EXC CSM V24 P236 <br />Current Zoning: F1 Floodplain Y/N: Y wetlands Y/N: - Lake/River Class: - <br />Name of water Body: Wood Lake <br />Farmland Preservation Y/N: - <br />Shoreland Agreement/SIPS Y/N: - <br />.Mana'g'ed Forestry Law Y/N: - <br />New Parcel Information <br />KIPM1 nnmhincri (:CM MnlMlinn rn foot Qv ii+h� rl� t n <br />Frupused New Legai Description and Parcel Size: "y "y <br />Lot 1 existing CSM V24 P236 <br />Acres: 1 •5 +/- <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: <br />Proposed access to public waters to be provided Y/r: <br />If yes, describe access: <br />Signature of Owner: �`� Flak, ReyiuocaB;Vw&de4 q C257Z <br />Signature of Owner: <br />Date: dci`wa 2018 <br />Date: <br />➢ Does parcel meet Zoning Requirements? Yes No %l, P.e.. 1)I �� 1$' <br />➢ Does parcel require a Survey? Yes No <br />➢ Permit application fees submitted.' ElAmount $ so , <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain:_,( I '� <br />Application: <br />Reason for Denial: <br />Receipt # <br />