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Fees(must eccoagmgr fam): <br /> Burnett County Subdivision Permit Application &ManidionWoSurvey: $5000 <br /> Stymy of&timing Parock and/or Pre-Application Form or Map Review Form sxoo..o'o `o. <br /> Teresa E Swenson frrev Trust <br /> 1 i <br /> owner: Chad A Olson lrrev Trust Buyer: <br /> Address;295 Calamus Circle Adds: 1 0 <br /> .Medina MN 55340 1 <br /> AY <br /> Phone: Phone: <br /> Original Parcel Informationfiç- <br /> Taim# \` <br /> : 07-020-2-40-16-23-5 05-003-015100 Secttan 23 Township 40N Ianie 16W <br /> Original Description(or attach copy):LOtS 1 &2 CSM V10 P133 & Lot 3 V17 P18 CL 3 <br /> cy ` <br /> current Zoning: RR1 Floodplain Y/N:Y Wetlands YIN: N Lake/River('.lava; l <br /> Name of Water Body:Johnson Lake Shoreland Agreement/SIPS Y/N: G CA <br /> \� <br /> Farmland Preservation YIN:N Managed Forestry Law YIN: N <br /> New Parcel Information <br /> Proposed New Legal Description and pared Six: CSM to combine 3 existing lots <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> El <br /> Proposed access to public waters to be provided YIN: :p <br /> If yes,describe access: <br /> !Signature of Owner: ' '. l n t. (°(t a t <br /> ue or vwdmr: 7 jv'b'k / ,clam: 4 0 110( Vb — __.. <br /> Fee Roc: �' 7, <br /> > Does panel meet Zoning Requirements? Yee No Check#: /y f®e z._ <br /> Does parcel require a Survey? Yes No 1 <br /> i <br /> Reconciles with Red Property Lister Yes No Date: <br /> If not,eaplain• g <br /> I <br /> App>Icati :,Approvd / n Reason for Dolma- <br /> Land IIse� „ Dodo: <br /> Ask /`'' 6 `7 2 2__`� <br /> 1 <br />