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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 wi Survey: $200.00+$50.00/lot <br /> ep <br /> Ck) <br /> ( Owner: (1\CY1�`111 ...P.V k 1iiaer: 3 <br /> X71 Glok, ,�v .�� <br /> z <br /> Address: Address: <br /> I in <br /> ,P II!a- \r tu5M3 u, <br /> Phone: S2n(12. 0 —7()° 3 Phone: SD <br /> Oriiinal Parcel Information r <br /> Parcel ID#: 15 I O Section 0<Township 3 Range /LI <br /> 0 <br /> Original Description(or attach copy): a <br /> A <br /> SEND <br /> r <br /> Current ZoningY Z-3 Floodplain Y/N: , p(r <br /> Wetlands Y/N: Lake/River Class: 1 <br /> Name of Water Body: `�-Q I`'`Al.) �I V �N Shoreland Agreement/SIPS Y/N; f \/ <br /> vs <br /> rc' <br /> Fr Farmland Preservation Y/N: N Managed Forestry Law Y/N: /,) <br /> o �1 <br /> �. New Parcel Information L �,, �, �vN <br /> Proposed New Legal Description and Parcel Size: S v(jc re 1 1 'L-1 CD- _\-►'� <br /> Nu0 t [ “ of s 7-- 39, K RL-. W <br /> _XC T' p-co,y Se__ C 0 t Acres: Q , b S_ <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) G <br /> m <br /> Proposed access to public road: l V �A6' <br /> Proposed access to public waters to be provided Y/N: \ () l <br /> If yes,describe access: � <br /> -11 <br /> Signature of Owner: — Date: <br /> Signature of Owner Date: <br /> a. <br /> D Does parcel meet 'ning Requirements? Yes No <br /> P D Does parcel require a Survey? Yes No ('� !/I/QQ <br /> /(� o� D PE.rmit application fees submitted? 0 Amount$ .57)`P— Res4?# `7�'7 7 <br /> f <br /> MA ir RRanciles with Real Property Lister No Date: 6/18/0‘ <br /> 9 <br /> m If 44.:xplain: <br /> c( a. ry o p <br /> PO oO 0 h <br /> eA' -- "v L <br /> A�►gcation: Approved / Denied Reason for Denial: <br /> Ig t V <br /> Lan�Use: ,---� z6z Date: <br /> J <br />