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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application subdivision w/o Survey: 550.00 <br /> and/tar Pre-A lication Form Survey of Existing Parcel: 550.00 lot <br /> pp Subdivision WI Survey: 5200.00 r S50.00lot <br /> Owner: Secluded Land Company Buyer: <br /> y <br /> Address:PO Box 10 Address: <br /> De Soto WI 54624 z <br /> Phone: 800-782-1126 <br /> Phone: <br /> Original Parcel Information <br /> Parcel ID# g: 07-016-2-39-17-23-2 02-000-011000 Section 23 Township 39N Range 17W �J <br /> Original Description(or attach copy): <br /> NW-NW b <br /> n <br /> Rs <br /> n <br /> Current Zoning: Fl Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: <br /> T Name of Water Body: N/A Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation YIN:N Managed Forestry Law Y/N•'' <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM divide into 4 parcels <br /> i'. 'f <br /> i Acres:40 \� <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> I <br /> Proposed access to public road: <br /> v <br /> Proposed access to public waters to be provided YIN: p? <br /> If yes,;describe access: � <br /> 1 ��j <br /> Signature of Owner: /oE2' �' Date: 0?//b/IC..") V <br /> Signature of Owner: "' <br /> Date: c <br /> 2 <br /> Doles parcel meet Zoning Requirements? Yes No <br /> cc-if6oZ� r <br /> N <br /> 3 ►- Does parcel require a Survey? Yes No <br /> Permit application fees submitted? 0 Amount s �o�r DD Receipt# <br /> .l <br /> r- 13 Recoesnciles with Real Property Lister No Date: 11112.aO -4) <br /> 11 <br /> °• If not,explain: <br /> e, <br /> i <br /> c <br /> a <br /> 1 <br /> Application. • pprov•• Denied Reason for Denial: <br /> Se pexPkie_ Alice— 20—o.; <br /> Land Us <br /> tea,,,,.,..► //40'e9 0l9 ZO Date: <br />