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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form Subdivision w/o Survcy: $10.00 <br /> Subdivision w/Survcv:El(X).00+$15.(X1/lo( <br /> Owner: / act< �(���r 11—za f <br /> Address: <br /> �7 3 <br /> Phone: ONjlj' 1631 e <br /> 020-q 32') <br /> OM400- 0 3000 - 03010 Oriainal Parcel Information <br /> 03 Z 0c, - iu 3 300 ,,II ( R <br /> Parcel Identification #:C� -737-6�IQ[t Section Z`f Township-'L6.&(Ran e <br /> g U � <br /> Original Description (or attach copy): !A/ l� <br /> O <br /> E <br /> e <br /> n <br /> Current Zoning: A Z Tb Floodplain )Q Wetlands Y <br /> Lake/River Classification: Name of Water Body: <br /> New Parcel Information <br /> Proposed NewDescription <br /> pos Legal and Parcel Size: <br /> a <br /> Ares: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Signature of Applicant: l�C(!(r�2 -c. Klzcw��z Date: Y, 9' <br /> 1 <br /> Q1 <br /> Does parcel meet Zoning Requirements No <br /> 0 <br /> aro <br /> > Does parcel require a Survey? Yes No R� <br /> > Permit application,fees submitted? ❑ Amount$ A <br /> Receipt# 3 <br /> e <br /> ❑Reconciles with Real Property Lister Yes No Date: <br /> a <br /> If not,explain: c° o D <br /> 3 w�` 4' <br /> w au ww <br /> Wp 000 <br /> Application: Approv / Denied Reason for Denial: <br /> ADO O�r' <br /> Land Use: <br /> Date:_ <br />