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im <br />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: 5200.00 + S50.00/lot <br />(Estate of EI Rose Johnson) <br />Owner: Steve Johnson Etal Buyer: <br />Address: 22267 Hegge Road <br />Grantsburq, WI 54840 <br />Phone: 715-220-6983 <br />Address: <br />Phone: <br />Original Parcel Information <br />Tax ID#: 33537 <br />Parcel ID#: 07-034-2-37-18-17-5 05-001-011001 Section 17 <br />Township 37 Range 18 <br />Original Description (or attach copy): See Doc.#453443 <br />Current Zoning: & A Floodplain Y/N: <br />Wetlands Y/N: <br />X4 <br />Lake/River Classification: Name of Water Body: <br />Bass Lake <br />Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N: <br />Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Proposed C S M <br />Lot 1 (9.6 Acres±) <br />Lot 2 (3.5 Acres±) <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for <br />preliminary map requirements.) <br />Proposed access to public road: Existing driveway north & west to North Bass Lake Road <br />Proposed access to public waters to be provided Y/N: N <br />If ves, describe access:-.� <br />Signature of Owner: ` Date: Z- /7-/7' <br />o= <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? <br />➢ Permit application fees submitted? <br />❑ Reconciles with Real Property Lister <br />If not, explain: <br />Yes No <br />O� <br />❑ Amount $ 3©�' Receipt # <br />Yes No Date: <br />I Reaso-n/ for Denial: <br />A4 Gvl T <br />