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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: 550.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Lisa Pandow. Erik Lokke,;. Subdivision w/Survey: $200.00—S50.00/lot <br /> Theresa Lokken-Janes <br /> Owner: Buyer: -0 <br /> m <br /> Address: '4 Stacy LN Address: 3 <br /> Fort Atkinson, WI 53538 z <br /> 0 <br /> .0 <br /> ,_ Pandow. 608-212-3`387 c <br /> Phone: Phone: CP <br /> Original Parcel Information CC7 <br /> Parcel ID#: Section 1 ' Township 39 Range Ci/Ip <br /> Original Description (or attach copy) Government Lot 2 except parcel descr?bec z <br /> E, <br /> tts•--0 <br /> Current Zoning: Floodplain YIN: Wetlands Y/N: Lake/River Class: eii pN <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N: <br /> 7-7 Farmland Preservation YIN: <br /> Managed Forestry Law Y/N: F <br /> �. New Parcel Information <br /> Proposed New Legal Description and Parcel Size: i""'�' ' { r <br /> b <br /> r <br /> Acres: f <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Sett L ke Roa m <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> Signature of Owner: ✓1 L Date: i: f�,y/, „,L tj <br /> ,��_Let �� �ct >z<CtiC��C� <br /> signature of owner: liate: <br /> 3 <br /> a <br /> r Does parcel meet Zoning Requirements? Yes No „. a / 7s-- f> <br /> N <br /> 'i-• Does parcel require a Survey? Yes No <br /> e,_....--aS. Y Permit application fees submitted? ❑ Amount$ 3vd, • Receipt# <br /> c�C <br /> ra <br /> 0 Reconciles with Real Property Lister Yes No Date: w <br /> 6 If not,explain: <br /> o. <br /> A <br /> en <br /> o <br /> n. App;; Approv Denied Reason for Denial: <br /> "9.,,,........Land Use: - / ®zjzsate: <br /> gee. V'e zorl e- /37A °-20-0 9 <br />