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Fees(must accompany form)* <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey:� <br /> Survey of Existing Parcel: S50.00/lot <br /> Application and/or Pre-Application Form Subdivision w/Survev: $200.00+S50.00/1ot <br /> Owner: U d/4 N/U e / 1 'jriU Buyer: <br /> A <br /> Address: ) &/017 Ute- Address: 3• <br /> S e.r y ed <br /> Phone: I��" �J l o� l / Phone: <br /> Original Parcel Information —� <br /> 07•-Day-a)-39- iy-lel -3 oy - ow o//600G <br /> Parcel ID#: O A`1-3// y-C a - TOL) Section�TownshipRange <br /> C <br /> Original Description(or attach copy): V (SLU Ydj <br /> Current Zoning: -D- FloodplainY&_ <br /> Wetlands Y6-) Lake/River Class: 5 <br /> Name of Water Body: LU Shoreland Agreement/SIPS Y6 <br /> o <br /> aFarmland Preservation /N: Managed Forestry Law 6�) <br /> New Parcel Infoormation - <br /> Proposed New Legal Description and Parcel Size: �y <br /> L4 W <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: L. 1�.)ti C G` <br /> m <br /> Proposed access to public waters to be provided IC/N-_ <br /> If yes,describe access: <br /> -� <br /> Signature of Owner: Date: - "- <br /> Signature of Owner: Date: 0 1 <br /> Does parcel meet Zoning Requirements? Yes No <br /> �s <br /> LN <br /> 7 Does parcel require a Survey? Yes Q::N:o !) d <br /> Permit application fees submitted.2 Amount$ 5C). <br /> 01) Receipt# <br /> W C <br /> r, Reconciles with Real Property Lister Ye, No Date: <br /> ¢' If not,explain: d <br /> o <br /> a QG <br /> Applicatio : Approved / hied Reason for Denial: <br /> Land Use: Date: �� <br />