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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> aPre-Application Form Subdivision w/o Survey: $I.000 <br /> and/or Pre-A <br /> PP Subdivisionw/Survey:SI00.00+$15.00/lot <br /> Owner: 1a1 al- / /C./ y&: et-"� <br /> L n <br /> Address: 5oy,)— tzo!ti <br /> _/ I'V MD/i$ Mitt' 5J11 Phone: o <br /> �tf <br /> l Parcel Information <br /> d10n y3��-0-4 lOri iv OZo-y3a- y <br /> Parcel Identification#: M-q312 -6 Section 12-13 Township Va/✓ Range 16 4y <br /> Original Description(or attach copy): 6.4• y /Z G• z' <br /> i�rc C5m V of P <br /> n <br /> a Current Zoning: 162 Floodplain Y V: WetlandsLWN: <br /> .. Lake/River Classification: (W:553 Name of Water Body: <br /> New arcelInformation <br /> Proposed New Legal Description and Parcell Size: 7- <br /> Acres / M 'f' <br /> (If parcel is to be surveyed, provide preliminary)map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> t7 <br /> Signature of Applicant: Date: <br /> CPi <br /> 1 <br /> Does parcel meet Zoning Requirement Yes No 6 <br /> 1) <br /> �• ➢ Does parcel require a Survey? Yes No <br /> e' o <br /> ➢ Permit application fees submitted? ❑' Amount S5 D' 1)1) Receipt# 5D3 9 <br /> e <br /> n <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> c pio oa <br /> �y mYi <br /> 7C! O o bn <br /> e If not,explain: <br /> o w Www <br /> W `}1NR3 <br /> 0 Oco <br /> Applicatio Approved / enied Reason for Denial: o mn <br /> a <br /> Land Use: Date: <br />