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Burnett County Subdivision Permit Application Fees(must accompany form) <br /> and/or Pre-Application Form or Map Review Form subdivisionwioSurvey: S5000 <br /> Survey of Existing Parcel S50.00flot <br /> Subdivision wi Survey S200 00+S50 00 1,11 <br /> Owner: Buyer: K <br /> 3 <br /> x38 12TH AVE N <br /> Address: Address: - <br /> S"" i_ MN o <br /> :til <br /> C <br /> Phone: Phone: <br /> Original Parcel Information <br /> Parcel ID#: Section Township Range s <br /> a <br /> Original Description(or attach copy): <br /> r3 <br /> Current Zoning: RR_i 1•loodplaia WIN: Wetlands N'/N: Lake/River(lass: <br /> ) ; <br /> Name of Water Body: Shoreland Agreement/SIPS YIN; <br /> Farmland Preservation YIN: Managed Forestry Law YIN: <br /> Vr <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: rt <br /> Proposed access to public waters to be provided YM: <br /> If yes,describe access: <br /> Signature of Owner: 1 ;" Date: 7 ---i - ,,, ( <br /> signature of Uwner: Date: 2 <br /> e <br /> > Does parcel meet Zoning Requirements? Yes Nu Cie--*"//X0 :; <br /> • Does parcel require a Survey? Yes No <br /> N <br /> O� <br /> 6' Permit application fees submitted? ❑ Amount$ 3D©, Receipt itXI <br /> 0 Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> 0 <br /> c <br /> X <br /> n <br /> n <br /> n Application pproved Denied for Denial: <br /> Land l se: Arid. �fZe Z./ Date: <br /> CN k) <br />