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Frrs(nma accompwy <br /> Burnett County Subdivision Permit Application swwivis oo W @$5o.00 <br /> SwvCy of Existims ice: Ssa oftt <br /> and/or Pre-Application Form or Map Review Form Subdivision W/Surny: $2W.00+sso.00na <br /> (�"C-" Sk�c�-��c� <br /> Richar achta d Sl Owner ' <br /> Owner: )g9fi,, Mary Beth Skunes Trust Agreement DTD <br /> Address:28057 S Johnson Lake Rd A . 102 Dylan Court ° o <br /> Webster W154893 Mahtomedi MN 55115 •00 rA <br /> Phone: �2�`A�l_`4�'� �S 1- t{2�ci��'JO� for4' <br /> Phone: <br /> Orisinal Parcel Information <br /> Tax ID#: 34053&13591 Semen 23 Town `l0 RaW 1 fi <br /> Original Description(or attach copy):Lot 15 CSM V25 P91,Lot 1 CSM VI P139 <br /> m <br /> Current Zoning: RR1 Floodplain Yft.�T Wetlands Y/N•N LakeMver Class: <br /> Name of Water <br /> may;Johnson Lake Shoreland Agreement/SIPS YIN: <br /> Farmland Preservati=YIN:N Managed Forestry Law YIN: N 4 , <br /> New Parcel Information <br /> Proposed New 2 Lot CSM H <br /> Legal Deacr�a and Parcel Size: <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 /> Proposed access to public waters to be provided YIN: W <br /> If yes,describe access: �� 1 <br /> Uj <br /> Signature of Owner Date,_ <br /> r ^ <br /> Signature of Owner: / Date: 1 Z— S—Z <br /> ➢ Does parcel meet Zoning Requirements? Yes No Fee Rec: 00. <br /> ➢ Does parcel require a Check &/Z/Sm'ney Yes No <br /> Reconciles with Real Property Litter Yes No Date: <br /> If not,explain. <br /> Appii Approved enied Reason for Danish <br /> Land se• Date_ <br />