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Fees (ntttst 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 Subdivisionw/Survev: $200.00+$50.00/lot <br />Owner: ML Holst LLC <br />Address: 852 138th St <br />Amery, WI 54001 <br />Phone: <br />Buyer: <br />Address: <br />Phone: <br />Original Parcel Information <br />Parcel ID 9: 07-040-2-39-19-27-3 04-000-011000 Section 27 Township 39N Range 19W <br />Original Description (or attach copy): SE SW <br />Current Zoning: RR3 Floodplain Y/N: NWetlands YIN: N Lake/River <br />Name of Nater Body:_ <br />Farmland Preservation Y. <br />Shoreland Agreement/SIPS Y/N: <br />Managed Forestry Law Y/N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: 2 New 3 lot Certified Survey Maps dividing parcel <br />Acres: 25 acres & 15 acres <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/Y: <br />If yes, describe access: <br />Signature of Owner: <br />Date:1/30111 <br />Signature of Owner: Date: <br />Does parcel meet Zoning Requireinents? Yes [Vo I,e.0 / � / <br />_ > Does parcel require a Survey. Yes <br />Q" i Permit application fees submitted? ❑ Amount S Receipt A <br />C, ❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />ti <br />r <br />0 <br />c. <br />y <br />Applicatio�pprovednied Reason for Denial: <br />Land Use: Date: ;71119 <br />!` <br />T_ <br />P <br />