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FEB-22-2006 01:24 WAGNER SURVEY 7158664206 P.002 <br /> ( VIML-7 I.dJwvl/ 1 "r U-1 ] jision <br /> ustaccompany form): <br /> I'b Burnett County Subdivision Perinit/Survey Revieision w/o Survey: $50.00 <br /> of Existing Parcel: SSO.DOIIot <br /> Md Application and/or Pre-Application Form w/Survey: 5200.00+550.001ot <br /> Owner: 11 t�y r r• CM C./I 'Buyer <br /> ro <br /> Address: Address: B <br /> /� � <br /> Phone: "' �` e,4- /�Qw Phone: <br /> 0�-oao-q�-Na�� 3y--5 ) ii?ii�nalParcel Info <br /> �rmat* dQ ,/ / ,,/ <br /> Parcel ID#: O1 Oa0-� y�-/b-3" /J0 'ecti n Township 'kJV Range 14•Y <br /> Original Descriptionor attach cop ): [fJ 9 M 0 OC <br /> (l�iC 7 <br /> �?he.� �: <br /> Current Zoning: Flt , U-!F(ilo-odplainON:' - '/ WetlandsAON: Lake(RiverClam: <br /> A_ <br /> a Name of Water Body: YX /6 �-#40Li Shoreland AgreementtSIPS Yo <br /> 7 <br /> Farmland Preservation Y/ Managed Forestry Law Y- N , <br /> 0 <br /> New Parcel Information j / <br /> Proposed New Legal Description and Parcel Size: 5� ✓��I I iI a <br /> Acres: • / <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> e . r. Ir <br /> Proposed access to public road: p <br /> Proposed access to public waters to be provided Y& <br /> _ G> <br /> If yes,describe access: <br /> Signature of Owner: ` Date: U 52 <br /> t ' <br /> Signature of Owner: Date: C / o <br /> m <br /> 9 <br /> C <br /> r Does parcel meet Zoning R uirements? Yes No „ <br /> i Does parcel require a Survey? Yes No ' <br /> U <br /> t' Permit application fees submitted? ❑ Amount$ Receipt d � 1} <br /> ❑Reconciles with Real Property Lister Yes No Date: o <br /> If not,explain: C) <br /> n � <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />