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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: $200.00+$50.00/lot <br /> Hay Creek Holdings, LLC <br /> Owner: Attn: Tim Tessman Buyer: <br /> CDAddress: 9469 N M u d h e n Lake Dr Address: <br /> Siren, WI 54872 <br /> Phone: 715-497-8854 Phone: <br /> Original Parcel Information p <br /> 07-010-2-38-19-16-4 03-000-012000 oe� <br /> Parcel ID#: Legacy#: 010261603620 Tax ID#: 4182 Section 16 Township 38 Range 19 C <br /> Original Description(or attach copy): See Doc.#437921 <br /> CDCD <br /> Current Zoning: Cl Floodplain Y/N: Wetlands Y/N: <br /> Lake/River Classification: Name of Water Body: Hay Creek <br /> Shoreland Agreemt or SIPS YIN: Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: Lot 4, Proposed CSM <br /> Acres: 6.0 Acres± <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: State Hwighway No. 70 C7 <br /> Proposed access to public waters to be provided Y/N: N <br /> If yes,describe access: <br /> Signature of Owner: Timothy S.Tessman „_,,.m_, -,-• - Date: <br /> Signature of Owner: Date: <br /> > Does parcel meet Zoning Requirements? Yes Noet <br /> N '+ <br /> o <br /> E. <br /> > Does parcel require a Survey? Yes No <br /> va <br /> Permit application fees submitted? 0 Amount$ Receipt# <br /> 0 Reconciles with Real Property Lister Yes No Date: <br /> a <br /> P7 If not,explain: <br /> O <br /> C. <br /> y <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />