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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> and/or Pre-Application Form Surveysionof w/Survc : $200.00OAw <br /> Sutxlivisionw/Survey: $_110.00+$S000tlW <br /> Owner: ;Te r. * `3oah L)c-�k1ke- Buyer: <br /> Address: 69083 gco:2� e- _�Ocsd Address: <br /> w <br /> Phone: 9 Sl - R l3- SYFo 1 Phone: <br /> Orieinal Parcel Information <br /> -02Alav <br /> Parcel ID 0: o7-0,28-a?-YQ-IY-09- os=gpa-022Qaa Section _Townshie Range <br /> Ori,-s;.-1 Description(or attach copy): Pe 1 G-ov. Q V .2 r!,L,o f 139) <br /> 'i- Pc l be_5 '*"1140 ,10'1 CY <br /> s <br /> 7 Current Zoning: FloodplainCYA:_Wetlands Y�N� iver Class: � <br /> aName of Water Body: F i SV- c k Shoreland Agreement/SIPS Ve—gp <br /> Farmland Preservation Y/N: ) Managed Forestry Law Y � <br /> New Parcel Information C � Y. a� Y, (00— <br /> Proposed New Legal Description and Parcel Sue: �'r cit C 1Ul Lc,}- <br /> Acres: O-O S <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: -0-* 5 i tt q s4 <br /> Proposed access to public waters to be provided V/N: g <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: <br /> C <br /> i Does parcel meet Zoning Requirements? Yes No <br /> 2. i Does parcel require a Survey? Yes No <br /> 00 i Permit application fres submitted? ❑ Amount S / Receipt d <br /> r ❑ Reconciles with Real Property Lister Yes No Date: <br /> m <br /> c If not,explain: <br /> X <br /> A <br /> n <br /> 0 <br /> a <br /> w <br /> Applicatio pproved / enied Reason for Denial: <br /> BURNETTLand Use: / `T Date: Z0Al1AVa <br />