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Fees(must accompany form): '. <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: S50.00 <br /> Survey of Existing Parcel: S50.00not <br /> R and/or Pre-Application Form Subdivision w/Survev: $200.00+S50.00not <br /> Owner: &rbOX-d M61I'wW Buyer: .o <br /> P <br /> Q V � <br /> Address: P U o A I5 Address: 3 <br /> /gym, �I,)�li SyGBO�Z <br /> Phone: 1 n/J� 3 -1 q — d.')1). Phone: <br /> ,Y/ Oriain/al,P,a/r`L06cel Information <br /> ID 2_Z6 <br /> Parcel #: D I - -O Y Section Township�Range ' t t/ <br /> Original Description(or attach copy): <br /> V <br /> 14o P 3$- 3q 6 . L. �. <br /> a <br /> Current Zoning: NC.0 Floodplain Y Wetlands Y V�: < <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS VR) Farmland Preservation I%O—Managed Forestry Law Y/ <br /> New Parcel Inforrmation <br /> Proposed New Legal Description and Parcel Size: Cd!J M1 — LO-r I i 6u{-1/ <br /> LPr I <br /> Acres: 2 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> fl r7 tl <br /> Proposed access to public road: 5. <br /> 1 � / t7 <br /> d <br /> Proposed access to public waters to be provided Y <br /> A <br /> If ves,describe access: <br /> e Signature of Owner: Dater (y <br /> o Oo <br /> 00 Signature of Owner: Date: o <br /> 3 <br /> 'C7 <br /> ➢ Does parcel meet Zoning Requirements? Yes N0 m <br /> u <br /> ➢ Does parcel require a Survey? Yes No <br /> D Permit application fees submitted? ❑ Amount$ U• Receipt# <br /> a ❑ Reconciles with Real Property Lister Yes No Date: c! <br /> .t; <br /> If not,explain: <br /> c <br /> c <br /> Applicatio Approved / enied Reason for Denial: <br /> Land Use: l Date: �� <br />