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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form or Map Review Form Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Subdivision w/Survey 5200.00+S50.00/lot <br /> Owner: Eric Carlsen Buyer: <br /> Address: 1892 22 1/2 ST Address: <br /> RICE LAKE WI 54868 0 <br /> 715-651-8695 <br /> Phone: Phone: <br /> Original Parcel Information p <br /> Parcel ID#: 028922502200 Section 5 Township 40 Range 14j <br /> Original Description(or attach copy): Lots 14 15 and the West 50' of Lot 16 Pine Knoll <br /> Subdivision <br /> N/A <br /> Current Zonin Floo n Y/N: Wetlands Y/N: €�i Lake/River Class: <br /> .s Lake <br /> Name of Water<Bo : ShoreIand Agreement/SIPS Y/N- <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> C <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: )-his CSM merges Lot 15 with the W50' of Lot 16, <br /> and separates Lot 14 back into a single lot. <br /> Acres: 2.13± <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Direct access to Pine Knoll Road d <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/N: N <br /> If yes, describe access: <br /> Signature of Owner: ' . ` Date: <br /> n <br /> signature of uwner: Late: ° <br /> b <br /> a <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> N ➢ Does parcel require a Survey? Yes No DEC 18 2019 <br /> Q ➢ Permit application fees submitted? ❑ Amount$ ' JLI ; Receipt# iett County oQ <br /> W <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> oIf not,explain: <br /> a <br /> CD <br /> 0 <br /> a Applicatio Approved / enied Reason for Denial: <br /> Land Use: Date: <br /> �lloul �O 5 4Y�r P,v G�Z �T re7 o ZfJ/7, <br />