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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: Richard & Theresa Goiffon Buyer: Lucas & Lydia Hetfeld <br />23195 Dunham Lake Road 23190 Dunham Lake Road <br />I <br />Address: _ Address: <br />Siren, Wi. 54872 <br />Phone: riehard.m.goiffonCaellsfargo.comPhone: <br />Siren, Wi. 54872 <br />OriOnal Parcel Information <br />Tax Id No. 2420 <br />Parcel ID #: Section 20 Township 38 Range 17 <br />Original Description (or attach copy): SE 1/4 of the SE 1/4, Section 20, T38N, R17W <br />Current Zoning: `a'2 Floodplain Y/N: Y Wetlands YIN: N Lake/River Class: N/A <br />Name of Water Body: N/A Shoreland Agreement/SIPS Y/N: N <br />Farmland Preservation YIN: N Managed Forestry Law YIN: N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: <br />North 660 feet of the West 660 feet of the SE 1/4 of the SE 1/4, <br />Section 20, T38N, R17W 10.00 <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Abuts Shuttleworth Road <br />Proposed access to public waters to be provided Y/N: N <br />If yes, describe access: <br />Signature of Owner: v <br />Signature of Owner: <br />Date: <br />Date: <br />➢ Does parcel meet Zoning Requirements? Yes No g e_e— 2/ 2 Z// 7 <br />➢ Does parcel require a Survey? Yes No C� e <br />v� <br />➢ Permit application fees submitted? ❑ Amount S Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />A <br />Land <br />Denied Reason for Denial: <br />Date: <br />Xo� <br />d <br />» <br />A <br />xt <br />