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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/Survey: 5200.00+550.00/lot <br />owner: Dale E Petersen <br />Buyer: <br />Address: 1377 West Point Rd Address: <br />Spooner, WI 54801 <br />Phone: <br />Phone: <br />Original Parcel Information <br />Parcel ID #: 07-028-2-40-14-25-5 05-002-027001 Section 25 Township 40N Range 14W <br />Original Description (or attach copy): PCL Gov Lot 2 DES V284 P630, EX CSM V14 P245 <br />& EX PCL in Gov Lot 2, Des in #435614 <br />Current Zoning: RR3 Floodplain Y/N: N Wetlands Y/N: Y Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: New 1 Lot CSM <br />Acres: 5.0 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Existing <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />Signature of Owner: <br />Date: <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No,p S/ryN aPP per, �Z8 <br />➢ Does parcel require a Survey? Yes yNol 9cc' Z/ <br />D � <br />➢ Permit application fees submitted? ❑ Amount $ zS �' Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />n: Approved / D9enied Reason for Denial: <br />d <br />a <br />A <br />