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Form Approved <br /> OMB No. 63—R1404 <br /> U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT <br /> FEDERAL INSURANCE ADMINISTRATION <br /> APPLICATION FOR PARTICIPATION IN THE NATIONAL FLOOD INSURANCE PROGRAM* <br /> DATE <br /> To be submitted to: FEDERAL INSURANCE ADMINISTRATOR <br /> Department of Housing and Urban Development,Washington, D.C. 20410 <br /> T y7 <br /> 1. APPLICANT (City, Town, etc.) z cb iip 27, j � <br /> Burnett County <br /> ADDRESS(County, State) <br /> isturnett CouT1ty, iii 3PrInain TELEPHONE <br /> 2. FFICIAL, OFFICE OR AGENCY WITH OVERALL RESPONSIBILITY(See Appendix A(2)) <br /> � ° I3 x�IV `` i 03.16?. r:xtion 715-366-4 61 <br /> A ree or o o., tt ate, IP o e <br /> Box 117 <br /> rr��}y:�`.��;yy�� ddII ��,�re <br /> 3. VRaGh7ATJr QO F'tL7TN+�TQ44fficial, if different from above, with responsibility for coordinating program) TELEPHONE <br /> ADDRESS(Street or Box No., City, State, ZIP Code) <br /> 4. FIRST FLOOR ELEVATION INFORMATION WILL BE RECORDED BY: (See Appendix A(3)) TELEPHONE <br /> �( t ,ou tyN adr>ii i tratar 715-866-4361 <br /> A tree or ox o., tt ate, IP o e <br /> Box 117 <br /> tiebster, JI 548393 <br /> 5. LOCATION-OF COMMUNITY REPOSITORY FOR PUBLIC INSPECTION OF FIA MAPS <br /> Burnett County Gffice Building <br /> ADDRESS <br /> Role 117, qI 5hM93 <br /> 6. ESTIMATES FOR ONLY THOSE AREAS SUBJECT TO FLOOD AND/OR MUDSLIDE <br /> AS KNOWN AT THE TIME OF APPLICATION <br /> NO. OF 1-4 NO. OF SMALL NO. OF ALL <br /> AREA POPULATION FAMILY STRUCTURES BUSINESS STRUCTURES OTHER STRUCTURES <br /> 45 acres 36 18 2 11 <br /> 7. ESTIMATES OF TOTALS IN ENTIRE COMMUNITY <br /> *NOTE: NO. OF 1-4 NC. OF SMALL NO. OF ALL <br /> Submit the first and second copies to the POPULATION FAMILY STRUCTURES BUSINESS STRUCTURES OTHER STRUCTURES <br /> Federal Insurance Administration; the <br /> third copy to the State Coordinator; Retain <br /> the last copy for your files. y • 61406- s 3 <br /> T1 -,HUD-1650 (4-73) <br />