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Fees(must accompany form)- <br /> Burnett County Subdivision Permit Application SubdivisionwloSurvey $50.00 <br /> Survey of Existing Parcel. $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survev $200.00+S50.00/1ot <br /> fzol3c—r�r 4 <br /> Owner: _ 5 Ect2(-ANNL= $Cy x5-7Z- Buyer: .ty <br /> R <br /> R <br /> Address: "7-t>4? FR-AIR-t t= 5SRPSS T7R Address: 3 <br /> SicjI UisrA A:k SSrc35- z <br /> 0 <br /> Phone: Phone: <br /> Original Parcel Information <br /> of 47-71-v4oz-loc <br /> Parcel ID#: _of 4z.z c¢ v Z Zj-o Section + Township 38 Range l.5- <br /> O <br /> Original Description(or attach copy): A IT A-cH urD � <br /> m <br /> 31 <br /> / <br /> a Current Zoning: FZ Z.1 Floodplain Y/N: N Wetlands Y/N: N/ Lake/River Class:_ <br /> 9 <br /> m Name of Water Body: Rt6 SAuh LAK G Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: Cr <br /> New Parcel Information � <br /> Proposed New Legal Description and Parcel Size: l-HlS 15 Tw o t5Xt STt,J G rjJ <br /> 0 <br /> D C-Sc Rt en arlS 5G1tJ6 lcr+ l3w ED INTO c/,J tt/C-tJ Lar— Sy, cirl <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C-J(f 5T1n1G Ace6�ff C <br /> m <br /> A <br /> Proposed access to public waters to be provided Y/N: ,✓ <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: o <br /> 3 <br /> 9 <br /> G <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> R <br /> e ➢ Does parcel require a Survey? Yes No <br /> 0 <br /> CT <br /> 00 D Permit application fees submitted? ❑ Amount$�tj O r I��� Receipt# " <br /> Su � <br /> r, ❑ Reconciles with Real Property Lister Yes No Date: p n <br /> If not,explain: 'p <br /> o t <br /> a <br /> � n <br /> C C <br /> Application Approved / enied Reason for Denial: ? C <br /> Land Use: ti Date: <br />