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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 Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: f-"%0,1Q, - Oft v" •�. S'Fa, �' Buyer: A <br /> Address: \\1�0 Cr t S�v't i \ G�. Address: <br /> 0 <br /> 2369 Slit i'�If 914D .. <br /> qUJ <br /> Phone: Phone: `FJ <br /> 11 21 <br /> b2600J 61l (<l4,6 td Original Parcel Information 9J <br /> Parcel ID#: 01 lo- 14-2-�1- O.1-60 rj Section '-_Township _Range _ <br /> O <br /> Original Description (or attach copy): C 5`m V o4%_S ° <br /> A <br /> cwt " 13 1e- 13� Lo l s t o=l! and Lilt 1 z->S <br /> a �� (PIrB•l•w� s <br /> Current Zoning: VIJ2•ila-( Floodplain Y& WetlandsOIN: <br /> Lake/River Classification: Name of Water Body: — d <br /> 1 <br /> Shoreland Agreemt or SIPS Y& Farmland Preservation Y&=Managed Forestry Law Y&= <br /> New Parcel Information y� G <br /> Proposed New Legal Description and Parcel Size: Lv1 C<r�'{' .e( ft'Vvey <br /> Acres: 3D <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Exidat.0t7 <br /> m <br /> Proposed access to public waters to be provided Y& <br /> CAl <br /> If ves,describe access: j <br /> i <br /> O <br /> N Signature of Owner: Date: � <br /> 0 <br /> 0 <br /> 5 n <br /> °Q Signature of Owner: Date: <br /> c <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> xe <br /> d ➢ Does parcel require a Survey? Yes No O 0 p p 0 <br /> Permit application fees submitted? ❑ Amount$ Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: r 94:1c' F <br /> �wY°ww <br /> If not,explain: <br /> Applicata Aenied Reason for Denial: <br /> Land Use //��2-- Date 3- 3 -0 <br />