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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+$50.00/lot <br /> Owner: Brian Wiederin Buyer: <br /> b <br /> m <br /> Address:834 205th Ave Address: i. <br /> Sommerset WI 54025 0 <br /> Phone: Phone: 'SP <br /> Original Parcel Information <br /> 4 <br /> 07-028-2-40-14-14-4 03-000-011000 Townshi 4p ON Range 14W C> <br /> Parcel ID#: Section 14 <br /> Original Description(or attach copy): SE-SE & SW-SE g <br /> A <br /> z <br /> b Current Zoning: RR3 Floodplain Y/N: N Wetlands Y/N: N Lake/River Class: <br /> ❑: <br /> AD Name of Water Body: n/a Shoreland Agreement/SIPS Y/N: <br /> R Farmland Preservation Y/N:N Managed Forestry Law Y/N:Ncg <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM divide in 2 parcels S' <br /> Gto <br /> vttAcres:41.87 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> 7 <br /> Proposed access to public road: d <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: K.1- ____ <br /> Signature of Owner: 52, /-t- (/� <br /> ( ieDate: 12/18/20 <br /> Signature of Owner: Date: <br /> e <br /> Does parcel meet Zoning Requirements? Yes No <br /> p ➢ Does parcel require a Survey? Yes No <br /> cri <br /> > Permit application fees submitted? ❑ Amount$ Receipt# W <br /> r ❑Reconciles with Real Property Lister Yes No Date: <br /> °' If not,explain: <br /> e <br /> o - <br /> c. <br /> Application: Approved / Denied Reason for Denial: (`.) <br /> Land Use: Date: <br />