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Fees(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 /> ill <br /> Owner: NULTU-) Buyer: a <br /> Address: Pa. BO x -3 7 / Address: � <br /> Phone: 26— 1 Q'2 Phone: <br /> O <br /> d'7 -OZb Z-rf0"llo 33-x] ri final a c 1 normation <br /> /i -00 -0//000 �� 33 ydr✓ �(o KK/' 41 <br /> Farce I #: O�O/� -a-'S9-/!o •-O// 0-5- JOS44lnt__�__Township—' J(A/ Range-&K/ <br /> Original Description(or attach copy): 33 T y,0 N C//a W o <br /> 0 <br /> p � <br /> Current Zoning: /Lie/ Floodplain/I: Wetland�Y N: Lake/River Class: <br /> V Name of Water Body: �V I / 15 La Ke, Shoreland Agreement/SIPS Y <br /> ro <br /> s Farmland Preservation Y(V Managed Forestry Law <br /> Y6. <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: � <br /> Acres: 4. $S <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> v <br /> Proposed access to public waters to be provided YAD. <br /> a <br /> If yes,describe access: 2 L A kt i •f j 9-) <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: o <br /> ➢ Does parcel meet Zoning Requirements? YesNo (3 S <br /> °o ➢ Does parcel require a Survey? Yes No o'6 <br /> 00 ➢ Permit application fees submitted? ❑ Amount$/ bl- D D Receipt# p <br /> G <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> y o Z <br /> If not,explain: <br /> � W <br /> w b <br /> r�r^ <br /> o '1 <br /> Application Approved / Denied Reason for Denial: O <br /> Land Use: Date: It/-d y1111 <br /> W o <br /> C, <br /> O G <br /> O G <br /> a <br />