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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+$50.00/lot <br /> Owner: Dawn Fern Buyer: <br /> b <br /> Address: 716 200th St Address: <br /> Baldwin, WI 54002 0 <br /> Phone: Phone: <br /> Original Parcel Information o�p <br /> 07-020-2-40-16-33-5 05-001-021000 <br /> Parcel ID#: 07-020-2-40-16-33-1 02-000-013000 Section 33 O Township 40N Range 16W <br /> Original Description(or attach copy): PCL Gov Lot 1 & S 4A NW NE <br /> t <br /> Current Zoning: RR1 Floodplain Y/N:--Y-Wetlands Y/N: N Lake/River Class: <br /> Name of Water Body: Devils Lake Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N:_ N Managed Forestry Law Y/N: N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: 1 Lot CSM of existing parcels to combine lots <br /> Acres: 4.34 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Existing C <br /> m <br /> Proposed access to public waters to be provided Y/N: n_ <br /> If yes,describe access: <br /> N <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: o <br /> a <br /> ➢ Does parcel meet Zoning Requirements. Yes No b Z ft tu- ► 11 ��� <br /> ➢ Does parcel require a Survey? Yes No j� (7 p�I <br /> °° ➢ Permit application fees submitted? ❑ Amount$ 60 ' , Receipt# �) <br /> t" ❑ Reconciles with Real Property Lister Yes No Date: <br /> a <br /> ° If not,explain: <br /> 7� <br /> A <br /> O <br /> Z <br /> CS <br /> y <br /> Applicatio . Approved / Denied Reason for Denial: <br /> Land Use: ' /Z 27 Zr l Date: <br />