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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/Survey: $200.00+$50.00/lot <br /> Owner: Kay Childs Estate Buyer: ,b <br /> !D <br /> Address: 28383 Dhein Rd Address: <br /> Webster O-,� <br /> Phone: Phone: ,3, <br /> YU <br /> Original Parcel Information i <br /> Parcel ID#: Section19 &24Township 40N Range 14& 15W <br /> Original Description(or attach copy): SE-NE, GL 1, FR SW-NW i <br /> A <br /> 07-012-2-40-15-24-1 04-000-011000, 07-012-2-40-15-24-5 05-001-011000 '� <br /> 07-028-2-40-14-19-2 03-000-017000, 07-028-2-40-14-19-5 05-001-019000 <br /> .ti Current Zoning. Floodplain Y/N: Y Wetlands Y/N: Y Lake/River Class: <br /> Name of Water Body: Birch Island pond Shoreland Agreement/SlPS Y/N: <br /> 1 kn <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N: Y <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: C <br /> 4 <br /> Proposed access to public waters to be provided Y/N: '' <br /> 9t-If yes,describe access: <br /> �, r N <br /> Signature of Owne .. � ,.. �'�2- ���._ Date: l� p Q2/ N <br /> I1 <br /> Signature of Owner: i1 I Date: /L ''29 2 / o <br /> a <br /> / J b <br /> P $ 4u J#-CP175/ F'' <br /> > Does parcel meet coni Requirements? Yes No <br /> v > Does parcel require Survey? Yes No ,.- <br /> al ,of) <br /> Permit application fees submitted? 0 Amount$ l©�1 Receipt# W <br /> .c. - <br /> t" ❑Reconciles with Real Property Lister Yes No Date: <br /> 1 ft <br /> a' If not,explain: IL) <br /> w CJI <br /> Applicatio i /) <br /> Approved enied Reason for Denial: ‘PCil <br /> Land Use: ��w- 12/50/W04 Date: <br />