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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: S50.00/lot <br /> and/or Pre-Application Form I Subdivision w/Survev: $200.00+550.00/lot <br /> Owner: Burton Ristrom Buyer: Karla uolmquist y <br /> A <br /> Address: 23746 Floyd Parker Drive Address: 23738 Floyd Parker DriveB <br /> z <br /> Siren, WI 54872 Siren, WI 54872 <br /> Phone: 715/689-2388 Phone: 612/791-1321 <br /> Original Parcel Information <br /> Parcel ID#: 006-2417-05 900 Section 17 Township_Ig Range_17 p <br /> Original Description(or attach copy): See Attached Addendum A <br /> z <br /> Me <br /> M <br /> Current Zoning: RR-1 Floodplain YIN: N Wetlands Y/N: N <br /> Lake/River Classification: Name of Water Body: Mudhen Lake F <br /> S <br /> Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N:_Managed Forestry Law Y/N:_ <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: See Attached Addendum B <br /> O <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Floyd Parker Drive d <br /> Proposed access to public waters to be provided Y/N: N/A A <br /> If ves,describe access: <br /> Signature of Owner: Date: <br /> DQ <br /> Signature of Owner: Date: <br /> 9 <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ?k <br /> ➢ Does parcel require a Survey? Yes No <br /> 0°4G <br /> Permit application fees submitted? ❑ Amount$ d Receipt# (/ a a <br /> m ❑Reconciles with Real Property Lister Yes No Date: <br /> a <br /> p7 If not,explain: <br /> o ` \ <br /> c Ul <br /> N <br /> C <br /> Applicatio Approved / De led Reason for Denial: O <br /> / n <br /> Land Use: Date: <br /> L <br />