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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: OA <br /> and/or Pre-Application Form or Map Review Form Subdivision w/Survey 200.00+$50.00/l0 <br /> // -0 <br /> Owner: l3 e %ON Buyer: 3 <br /> �a a <br /> Address: z9'Ff5 'gk' ST, Address: <br /> Qhs .7L 4elne <br /> / //2/Lorph e � <br /> Phone: 6.30^�p _ 77/74f6.�Q—. ////^Phone: <br /> o 7- bBg- a - 10-1L177 7 35-332--Orleina arcel innformation <br /> O <br /> q � <br /> Parcel ID#: (�a -y%%q Q �' g8U Section { Township 1.0 Range 1410 °m <br /> Original Description (or attach copy): G• CO t-�lL /v �w F �) KG f-1 <br /> Py (2Sm U01 1(0 " ✓J� al o <br /> Current Zoning: Floodplain1f/N:1 Wetlan s Y Lake/River Class: 'v� <br /> o Name of Water Body: N A_ 1�� Shoreland Agreement/SIPS Y/ — <br /> •o <br /> d Farmland Preservation Y�1G� Managed Forestry Law Y6 <br /> 0 <br /> New Parcel <br /> /I�nfl� t Information <br /> Proposed New Legal Description and Parcel Size: Css t / G O f t ' 4 <br /> Acres: O! • c3 /r)4 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: PA-2 'Q J <br /> k M r'•"�Ik2,5 <br /> ,5 e 1 <br /> WProposed access to public waters to be provided Y � <br /> Q� <br /> If yes,describe access: <br /> Signature of Owner:/ Date: <br /> 9 <br /> Signature of Owner: Date: � <br /> ➢ Does parcel meet Zoning Requirements? Yes No ,u <br /> Does parcel require a Survey? Yes No ` Klr9� ,elr�j'J <br /> Permit application fees submitted? Amount$ Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: �I <br /> O <br /> If not,explain: <br /> o <br /> 9.1 V <br /> a Application: Approved / Denied Reason for Denial: G <br /> y <br /> d <br /> Land Use: Date: 0 <br />