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1.4N11 Ser i i c e . <br /> 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 w/Survey: $200.00+$50.00/lot <br /> b <br /> Owner: Ntsa-\< 1LwooP Buyer: i <br /> Address: 2-q 30 13a.Sha►rJ k.-0.V-t. 2a.z Address: P <br /> 54.e_l 1 t...,14-0_ u)1 54-(1'11 C <br /> Phone: /15 - q 39 -`)232- Phone: <br /> 1 <br /> Original Parcel Information op <br /> Parcel ID#: Tay ID 321 Section Township Range <br /> Original Description(or attach copy): I4E-140, cc-1-:a•. I-). 7 m1,AI 214-LJ I <br /> '7 <br /> 3 <br /> ' Current Zoning: / ! Floodplain Y/N: Wetlands Y/N: Lake/River Class: '/'i <br /> � Y / <br /> ti Name of Water Body: Gt i Li �l4 � Shoreland Agreement/SIPS Y/N: <br /> na <br /> pFarmland Preservation Y/N: Managed Forestry Law Y/N: 0 <br /> ., <br /> New Parcel Informations <br /> Proposed New Legal Description arid ParcelSize: ro 9 5C4 C.9,1 <br /> Acres: <br /> (If parcel is to be surveyed,provide'preliminary map. See attached for preliminary map requirements.) d <br /> g <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: _ <br /> ro <br /> Signature of Owner• <br /> _ * K_ Date: -425/toZt 12 <br /> Signature of Owner: Date: <br /> VI <br /> ➢ Does parcel meet Zoning Requirements? Yes No C-4-te�#//qq <br /> �O <br /> ILI <br /> c D Does parcel require a Survey? Yes No ..D <br /> E. <br /> Permit application fees submitted? ❑ Amount$ 2-50' a� Receipt# <br /> ®Reconciles with Real Property Lister ® No Date: 7-a9 -a/ <br /> t^ <br /> to a If not,explain: <br /> a <br /> a Applicatio A rov•1 .....-MI6 i e d Reason for Denial: <br /> Land Use: Date: <br /> -.dill 111 <br /> fii7?� a I <br />