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tees Imus[accompany corm/: <br /> Burnett County Subdh ision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: S50.0011ot <br /> ap u��r,�re-Application Form Subdivision w/Survev: 5200.00+550.00/lot <br /> ON COMPU-EMSGA,NINEi) <br /> owner: Robert & Carolyn Polkinghorn Buyer: Christopher & Amy Bangs _ y <br /> Address: 28169 South Johnson Lake Road Address: 8846 Pheasant Run Road _ <br /> Webster, WI 54893 Woodbury, MN 55125 e <br /> Phone: 715-866-8575 Phone: 612-850-6213 _ lQj <br /> } <br /> Original Parcel Information <br /> Parcel 1D #:part of 020-4323-07 800 Section 23 Township 40 Pange 16 <br /> Original Description (or attach copy): Lot One (1) of Certified Survey Map #3841, <br /> Y Document ta6335 0 in Volume 19 Pages 283-284 being located in Government Lot <br /> V 6, Section Twenty-three (23) , Township Forty (40) North, Range Sixteen (16) lies <br /> ourne oun y, 1sconsin <br /> Current Zoning: Floodplain Y/N: Wetlands Y/N: <br /> Lake/River Classification: Name of Water Body: Ov <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: SEE ATTACHED PARCEL INFORMATION. S <br /> a <br /> s <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> t7 <br /> m <br /> Proposed access to public waters to be provided Y/N: m <br /> If yes, describe access: 4— <br /> t� Signature of Owner: Date: <br /> 0 <br /> 0° Signature of Owner: �z` Date: �' —�� 9 <br /> ➢ Does parcel meet Toning Requirements? Yes No F; <br /> at <br /> ro ➢ Does parcel require a Stavey? Yes No <br /> C3 <br /> permit application fees stebniitted? ❑ Amount$ dU l�'rceipt # 7 O <br /> a ❑ Reconciles with Real Property Lister YesNo Date:__ <br /> If not.explain:_ W <br /> , ` y I <br /> J <br /> Applicatio Approved / ied Reason for Denial: Q <br /> 6 <br /> Land Use: Date:7 IT O <br />