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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/ Survcv: $200.00 -* $50.00/lot <br />Dan Glockzin <br />Owner: (of Dan Glockzin Trust Agreement) Buyer: <br />Address: 11447 North Shore Drive Address: <br />Grantsburq, WI 54840 <br />Phone: 715-689-2234 <br />Phone: <br />Original Parcel Information <br />07-042-2-38-18-27-5 15-395-026000 <br />ParcellD#: 07-042-2-38-18-27-5 15-395-027000 Section 27 Township 38 Range 18 <br />Original Description (or attach copy): All of Lots 2 and 3, Certified Survey Map No. 3843, <br />recorded in Volume 19, Pages 287-288 as Document No. 363618, iocoted in Government Lot 6, <br />Section 27, Township 38 North, Range 18 West, Town of Wood Lake, Burnett County, Wisconsin. <br />Current Zoning: R R 1 Floodplain Y/N: Wetlands Y/N: <br />Lake/River Classification: Name of Water Body: Wood Lake <br />Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Lots 11 AND 12, Proposed CSM <br />Acres: 3.06 ac <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: North Shore Drive <br />Proposed access to public waters to be provided Y/N: <br />If ves, describe access: <br />Signature of Owner:�s r Date: <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? Yes N <br />Rec'�. g -Is . 10ig <br />Permit application fees submitted? ❑ Amount $ 300• DU Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application< Approved /Denied Reason for Denial: <br />Land Use: <br />2-0/q <br />Date: <br />W <br />