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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 or Map Review Form Subdivision w/Survey: $200.00+$50.00/lot <br /> Owner: €-4'4 44 `x`46"/ 6171(4 Buyer: <br /> Address: Address: <br /> by <br /> Phone: Phone: <br /> Original Parcel Information ] <br /> Parcel ID #: Section Township S° Range /1 <br /> Z•401-2•31 <br /> L o <br /> Original Description (or attach copy): l��l � G a• 20. <br /> eo <br /> Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: 3 <br /> GName of Water Body: 14/IQ Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: Go P44 <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/N: <br /> If yes, describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: <br /> � <br /> ➢ Does parcel meet Zoning Requirements? Yes No C ,`L, ©� (D 3 7� J <br /> N ➢ Does parcel require a Survey? Yes No <br /> D. <br /> Permit application fees submitted? ❑ Amount$ 'OD! Receipt# <br /> CfQ <br /> 0 Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> • <br /> 7D <br /> Application. • ppr. •., •d Reason for Denial: <br /> Land Use: I Date: ,s/0.0Z1 <br /> GH110 ,s a �b.i„\ m"1C-mwue044/P �7�u7/-ule, 703 <br />