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FEB-06-2006 07:29 WAGNER SURVEY 7158664206 P.002 <br /> Fees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey; $50.00 X <br /> Application and/or Pre-Application Form Suof ting Parcel; 550.00/(01 <br /> PP Subbdidivv isionn wl Survev; 5200.00+550.00/lot <br /> Owner: /'II Chat f 64"C t �: <br /> a <br /> Address: X303 � a�m� reAddress: <br /> ./(..�� <br /> ess: <br /> eve, . vi 5Y813 baa <br /> Phone: Phone: /!d i"/ ZZ &i_/ (1) <br /> i <br /> pp �/Original Parcel Information ! <br /> Parcel ED M: D�-0 2 p'1- `/0-17" /4-J 60or�et�naTownship f0,c/ Range%/4✓ <br /> / - T ,,,,,,/// ��) V .! PZ 0/6 <br /> Original D scription(or attach copy): . �-!! 'z �+,( f <br /> ot 5 �r <br /> Current Zoning: e) os- Floodplain ()4:—Wetland V: Lake(River Class: <br /> 9 Name of Water Body: Shoreland Agreement/SIPS Y&— <br /> Farmland PreservationY Managed Forestry Law Y <br /> New ParcellInformaticm q <br /> Proposed New Legal Description and Parcel Size: 1.6/)l &7a_ <br /> / A i � U ,ee.z' ism ✓ a77 y�110(/�ya / <br /> Acres: d T 7 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for pre iminary map requir/e�ments.) <br /> Proposed access to public road: 2d - 2d <br /> O <br /> R <br /> Proposed access to public waters to be provided Y/�v:) <br /> If yes,describe access: l/` — <br /> Signature of owner: Date: <br /> Signature of Owner: Date: <br /> 3 <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> N <br /> z <br /> ➢ Does parcel require a gurney? -Yes No d <br /> a°o <br /> D Pemrir application fees submitted? 13Amount S 5b, __:_3� 0O Receipt N p. <br /> Oo <br /> r, ❑ Reconciles with Real Property Lister Yes No Date: Sl.� <br /> If not,explain: o <br /> n � <br /> Applicatio 7Amproved Denied Reason for Denial: <br /> r/ g <br /> Land Use: Date: d! OI <br /> J <br /> 0 <br /> O <br />