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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: $50.00/1ot <br /> and/or Pre-Application Form � Subdivision <br /> Nv/Survev: $200.010+$50.00not <br /> Owner: X CcIT G �G WC_k ` �( <br /> Buyer: 117tU16 l f . 1 CJI W e- <br /> I ( o <br /> �J A <br /> Address: 919D C1� RQ Address: 15� C-U_ 4 3 <br /> z <br /> rbk.rti I,t)s 518� ��H WS Stf 8 30 ° <br /> Phone: <br /> 115 Sb- 3 7 Phone: <br /> Original Parcel Information / / <br /> Parcel ID#: ����T /- 63' ��D Section__j TownshipA U Range A0 . <br /> Original Description(or attach copy): <br /> SW '/4 S �/� o <br /> m <br /> 3 <br /> D Current Zoning: Floodplain Y/N: Wetiand&Y N: Lake/River Class: <br /> 3 <br /> eName of Water Body: Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: Managed Forestry La Y : ('z' <br /> d <br /> New Parcel Information c <br /> Proposed New Legal Description and Parcel Size: lQCl'� <br /> Acres: 0 - a3 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> A <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe ac 4�) <br /> i <br /> Signature of Owner: Date: I S <br /> G <br /> Signature of Owner: Date: <br /> 9 <br /> C <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> a <br /> ➢ Does parcel require a Survey? Yes No 0 <br /> 00 ➢ Permit application fees submitted? ❑ Amount$ L7 Receipt# c <br /> t <br /> r ❑ Reconciles with Real Property Lis(ek Ye No Date: <br /> e O <br /> If not,explain: <br /> � C <br /> o w <br /> C <br /> CL <br /> � <br /> O <br /> Applicat< Approved / enied Reason for Denial: C <br /> G <br /> Land a ����'i Date• �� <br />