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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form or Map Review Form Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Subdivision w/Survev: %200.00+$50.00/lot <br /> Owner: Todd & Amy Hollenkamp Buyer: <br /> Address: 6655 Hideaway Road Address: <br /> Siren, Wl 54872o <br /> c <br /> Phone: Phone: <br /> Original Parcel Information <br /> Parcel ID#: 07-030-2-38-16-03-5 05-010-018300 Section 3 & 10 Township 38 Range `? C5- <br /> Original Description(or attach copy): Lot 3 CS No. 4713, vol. 26, p. 130-132t <br /> 1 <br /> Current Zoning: RR-1 Floodplain Y/N: Y Wetlands Y/N: Y Lake/River Class: <br /> N/A �^ <br /> fl Name of Water Body: Clam Lake Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br /> ° <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: We are submitting a new CSM that <br /> creates two new lots. The backland is designated as an Outlot due to wetland. <br /> Acres: 19.35 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Hid t access o ewa <br /> Proposed access to public road: Directy Road <br /> Proposed access to public waters to be provided Y/N: N a <br /> If yes,describe access: <br /> Signature of Owner: N/A Date: <br /> n <br /> Ntgnature of uwner: tuate: ° <br /> B <br /> b <br /> a <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> N ➢ Does parcel require a Survey? Yes No C>,J <br /> 0 <br /> 0 <br /> Permit application fees submitted? ❑ Amount S Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> a <br /> a <br /> 0 <br /> o Application: A / Denied Reason for Denial: <br /> Land Use: ? �l Date: <br />