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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/oSurvey: $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 /> T <br /> Baldwin, WI 54002 0 <br /> Phone: Phone: . <br /> Original Parcel Information o� <br /> 07-020-2-40-16-33-5 05-001-021000 Cl�` <br /> Parcel ID#: 07-020-2-40-16-33-1 02-000-013000 Section 33 Township 40N Range 16W <br /> O <br /> Original Description(or attach copy): PCL Gov Lot 1 & S 4A NW NE <br /> .o Current Zoning: RR1 Floodplain Y/N:�_Wetlands Y/N: N Lake/River Class: <br /> o CFI <br /> Name of Water Body: Devils Lake Shoreland Agreement/SIPS Y/N: ' I <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 /> Proposed access to public waters to be provided Y/N: n— <br /> If yes,describe access: <br /> Signature of Owner: Date: - <br /> Signature of Owner: Date: o <br /> ➢ Does parcel meet Zoning Requirements. Yes No <br /> � A c-c- <br /> ➢ Does parcel require a Survey? Yes No �� j� (� p 1 S <br /> Q° ➢ Permit application fees submitted? ❑ Amount S ` / Receipt# s) <br /> r. ❑ Reconciles with Real Property Lister Yes No Date: <br /> 0 <br /> 0 <br /> Q If not,explain: <br /> 0 <br /> -s <br /> a <br /> H <br /> Applicatio Approved Denied Reason for Denial: <br /> Land Use: ___ /Z 2 7 Zv/ Date: <br />