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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: $50.00/lot <br /> and/or Pre-Application Form or Map Review Form Subdivision w/Survey: $200.00+$50.00/lot <br /> b <br /> Owner: NJ }Ca.Q C-ea..7 X Buyer: ., @ <br /> C %» <br /> m <br /> Address: 0 cS o X AZ— Address: <br /> ba..‘au Ty kA)\ 54'9, 0 N <br /> Phone: G I Z. - 2 12-- I 06 01 <br /> Phone: <br /> 1.:t <br /> Original Parcel Information k <br /> Tax ID#: .7--f(7)q S Section Township_AL_Range 1(e <br /> O <br /> Original Description(or attach copy): -3 rD <br /> x " <br /> y <br /> o <br /> vrri <br /> A <br /> a <br /> z <br /> a <br /> Current Zoning:_8_R Floodplain Y/N: Wetlands Y/N: Lake/River Class; '0 <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N: y <br /> rA <br /> a <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> 0 <br /> New Parcel Information z <br /> c <br /> Proposed New Legal Description and Parcel Size: n <br /> m <br /> a <br /> y <br /> Acres: i <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: d <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> v <br /> Signature of Owner '`�� 4 4 Date: / <br /> Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning Requirements? Yes No ANd AQ OD <br /> Fee Rec: e C <br /> ,' 5711 a 30ill Check#: .mil/D <br /> ➢ Does parcel require a Survey? Yes No <br /> Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> Applicatio.: Approved / D• I ied Reason for Denial. <br /> Land Use: Date: <br /> J <br /> y zY490- <br />