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Fees{must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision wo Survey: $50.00 <br /> and/or Pre-A lieation Form Survey of Existins Parcel: $50.00=lot <br /> p p Sttbdiyision w,`Survey: $200.00 $50.00%lot <br /> Owner: Secluded Land Company <br /> Buyer: <br /> e' <br /> PO Box 10 <br /> Address: Address: 3 <br /> De Soto WI 54624 z <br /> Phone: 800-782-1126 <br /> Phone: 6' <br /> Original Parcel Information <br /> 160, <br /> Parcel 113#: 07-010-2-38-19-09-1 02-000-011000 Section 09 Township 38N Range 19W UI <br /> NW-NE <br /> Original Description(or attach copy): <br /> n <br /> n <br /> R <br /> RR-3 <br /> Current Zoning:, Floodplain YIN: N Wetlands Y/N: N Lake/River Class: <br /> Name of Water Body: N/A Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation YIN:N Managed Forestry Law YIN:Y <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: 2 CSM divide into 8 parcels <br /> Acres:40 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> IF <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> Signature of Owner: Date: 0`/fj£�/00 tloge u-1/7/fr <br /> et l4..,. (1,,r r t„c, t <br /> Signature of Owner: Date: n <br /> 0 <br /> > Does parcel meet Zoning Requirements? Yes No <br /> R w fr49 C <br /> N �a/3o 749 <br /> c i' Does parcel require a Survey? Yes No <br /> A' <br /> W <br /> Permit application fees submitted? 0 Amount 5 Receipt# "0 <br /> ii <br /> t•- es Reconciles with Real Property Lister No Date: II/W/O CI1 <br /> m <br /> it If not,explain: <br /> c <br /> a. <br /> y <br /> Application: Approved / Denied Reason for Denial: <br /> See. Rezene_ /MP- 20-p(* ap jA,gved for AR-3 <br /> Land Use- <br /> -2-11:14-4S---5...........L Date: i/t'p/ZO 20 <br />