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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: $50.0010t <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: _�r�N(�2Dp S �c2t-1A �/G Buyer: /lel / /7 <br /> Address: N`1 S66 gIGN��I L41N6_ Address: <br /> Uf <br /> Phone: lJ - d Phone: (� <br /> Orieinal Parcel Information <br /> Parcel ID#: Section ?!y Township?JG <br /> // Range� O <br /> Original Description (or attach copy): <br /> N <br /> ,a S' <br /> oCurrent Zoning: /Floodplain Y/N: Wetlands Y/N: <br /> Lake/River Classification: r r 1 Name of Water Body: <br /> Shoreland Aereemt or SIPS Y/N: /' � Farmland Preservation Y/N: tJ Manaeed Forestry Law Y/N: IJ y <br /> New Parcel Information 4 <br /> Proposed New Legal Description and Parcel Size: ` S <br /> CsM Of C'xtsy1� f— <br /> lG nacEZ <br /> a <br /> Acres: ' <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) (� <br /> Proposed access to public road: t +e C J ! <<PS< �� 70 Le(hof' d <br /> Proposed access to public waters to be provided Y/N: <br /> If ves,describe access: <br /> Signature of Owner: Ps N 0 C cl��V t S t O� Date: 6 <br /> o T 09 <br /> ° <br /> o° Signature of Owner: Date: Ic <br /> c <br /> 3 <br /> r <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> 1 <br /> m ➢ Does parcel require a Survey? Yes No <br /> ° � Q <br /> � D Permit application fees submitted? ❑ Amount$ �• �O Receipt# <br /> w ❑Reconciles with Real Property Lister Yes No Date: U <br /> If not,explain: <br /> O <br /> 1 <br /> O <br /> Application: pproved / Hied Reason for Denial: L~ <br /> Land Use: Date: <br />