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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: $200.00+550.00/lot <br /> Tzop'cn-T- 4 <br /> Owner: 5 V0mE ANNL= Sey x5_7z— Buyer: <br /> -qs <br /> Address: -i:tS4P VP-AIall: 61445 bR Address: <br /> Sic-tcrzA UIsrA <br /> Phone: Phone: <br /> Original Parcel Information <br /> �14Z1- 4-0zlEo_ SJ <br /> Parcel ID#: e-1 ¢LZ c¢ O Z Zc o Section + Townsbip 3S Range lS <br /> O <br /> Original Description(or attach copy): fl rrAOH ED <br /> n <br /> 9 Current Zoning: FZrZ 1 Floodplain Y/N: N Wetlands YIN: >`? Lake/River Class: j <br /> 9 <br /> Name of Water Body: Ht6 SAuh LLAKG Shoreland Agreement/SIPS YIN: <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: 6 <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: THIS 15 Tw o &Xt S T/�) G �J <br /> 7 <br /> 9 CSC RI Pr70'NS 6G103 <Ortt31nt ED Int Tb ONE /jc-u L..of 4;V GSM T <br /> Acres: t,3 5- <br /> (If <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: E-X 15 it^1 G .4c &rrf ty <br /> w <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: U <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: o <br /> B <br /> _ 9 <br /> C <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> a <br /> ➢ Does parcel require a Survey? Yes No <br /> e <br /> 00 D Permit application fees submitted? ❑ Amount$�j O i (��� Receipt# -� <br /> Su sv <br /> r, ❑ Reconciles with Real Property Lister Yes No Date: �j n <br /> t -C <br /> If not,explain: <br /> n � � <br /> n <br /> � � 1 <br /> 1 <br /> a � n <br /> CC <br /> Application Approved / enied Reason for Denial: <br /> Land Use: '+ Date:�"�,.J '�G <br />