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Pees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Application and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> PAM Locr WA616 <br /> Owner: M 1 TG.14 Buyer: � <br /> Address: ZS1 S m� K1 N�tt� Sr Ns Address: • <br /> 0 <br /> M t N N GA tea t_1 t in rl 554 I$ .. <br /> U.1 <br /> Phone: Phone: <br /> Orieinal Parcel Information <br /> 4p000 <br /> Parcel ID#: o"1 O o(o z 3$ 11 21 S o 200(0 0'Section Z( Township 3$ Range b� O <br /> Original Description(or attach copy): <br /> n <br /> fi <br /> Current Zoning:JZQ I Floodplain Y/N: r! Wetlands Y/N: Lake/River Class:_L_ <br /> ,a Name of Water Body: Dunt HpM Shoreland AgreemenUSIPS YIN• $- <br /> m Farmland Preservation YIN: /J Managed Forestry Law YIN: 1\/ <br /> 0 <br /> New Parcel Information <br /> 4 <br /> Proposed New Legal Description and Parcel Size: 1 K f S 15 A+`t et1 S ri fJ6 P4'Mc'rr L <br /> Acres: O <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: DuNHprn aeG DO— <br /> Proposed <br /> 2Proposed access to public waters to be provided Y/N: _ <br /> If yes,describe access: Lo f <br /> 0 <br /> Signature of Owner: Date: ,p <br /> Signature of Owner: Date: 3 <br /> 9 <br /> C <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> — xt <br /> e ➢ Does parcel require a Survey? C_Yes <_�No_ p <br /> 00 ➢ Permit application fees submitted? ❑ Amount$5 Receipt# <br /> r., ❑Reconciles with Real Property Lister Yes No Date: � <br /> o <br /> °• If not,explain: <br /> C, <br /> b <br /> Application• Approved / enled Reason for Denial: (5 <br /> Land Use: Date: <br /> r <br />