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Fees(must accompany Conn): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00M <br /> ,(._ and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: 1 f��/ Pt�Ay'S O Buyer: /t/14 <br /> Address: ZFS' -r0 /—A— t<rt. Address: <br /> �ahbvr w� s�IS�3tJ z <br /> •� D� P p� o <br /> Phone: / �S' p l� L - p O �i Phone: CAJ <br /> aLoq-3/$'o zSoc�OrieinalParcellnformation W <br /> Parcel ID#: 6 zo¢ 3/:;o 2.f3/o Section_/�;_ Township Range1(o <br /> O <br /> Original Description(or attach copy): <br /> m <br /> 3 <br /> R <br /> T Current Zoning: f( Z Floodplain Y/N: N Wetlands Y/N: Al <br /> Lake/River Classification: Name of Water Body: H <br /> 4 � <br /> Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N: �l Managed Forestry Law Y/N: Al <br /> _ S <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: 3 1-7-5 Sy CSM PC.us <br /> O.v � buTLoi T--o2. A-Cf�Sf <br /> Acres: <br /> 3 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: AGC COTS TD /=/LOM' Ccuf r /ZD G y <br /> m <br /> A <br /> Proposed access to public waters to be provided Y/N: /f J <br /> If ves,describe access: <br /> 4- <br /> Signature of Owner: //- Date: Z 1 <br /> Signature of Owner: Date: o <br /> H <br /> C <br /> ➢ Does parcel meet Zoning Requirements? Yes No g <br /> N � <br /> u <br /> ➢ Does parcel require a Survey? Yes, No 0 <br /> 00 L100,0() <br /> J a <br /> Permit applicationfees submitted? ❑ Amount$ 10 d,d() Receipt# O <br /> m ❑ Reconciles with Real Property Lister Yes No Date: 9' <br /> If not,explain: <br /> e s � <br /> � � L <br /> a � � <br /> 0 0 <br /> Application; Approve / Denied Reason for Denial: •fi;� <br /> 0 <br /> X 0 0 <br /> Land Use: Date: <br /> o G <br /> cc <br /> 00 <br /> 0 <br />