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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Survey ion w/o Survey: $50.00 <br /> `J pp Survey of Existing Parcel: $50.00/lot <br /> and/or Pre-Application Form or Map Review Form Subdivision w/Survev: $200.00+$50.00/lot <br /> n 11 /� �+' <br /> Owner: Rt?u 17Crj • S4ra nVs&— Buyer: r dJrQO.7d. Qtb�ye_S <br /> Address: <br /> 10 O� M1..O� 070W Address: `Jot-7 r ,W 7o <br /> n�!00"Cr I, M <br /> W11 v`11CA61 !PODA eC.c—, t�T $'/S <br /> rod <br /> Phone: 1,5— �I.WS— ` ;L55 Phone: - L� 5 Uv"" - a3 O <br /> 0 <br /> /h� Original Parcel Information p <br /> Parcel ID#: 1�3 Lo Q C Section Say Township�N Range <br /> Original Description (or attach copy): J J <br /> tt <br /> Current Zoning: Floodplain Y/N: I V Wetlands Y/N: Lake/River Class: <br /> Y Name of Water Body: Shoreland Agreement/SIPS Y/N• <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> New Parcel Informationo <br /> Proposed New Legal Description and Parcel Size: �n c- � tVa, <br /> �e 5e. I/mac Vle T31 Q1K v <br /> Acres: OG O f9 <br /> (If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road- <br /> Proposed access to public waters to be provided Y/N: �b <br /> .ti <br /> Z <br /> If yes,describe access: U <br /> c <br /> Signature of Owner: -��-'�''"`� �`' >ti�.-��- Date:/� —�) 5 <br /> Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> N ➢ Does parcel require a Survey? Yes No <br /> o � <br /> 0 T <br /> ➢ Permit application fees submitted? Amount$ ( l (� Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> d <br /> � If not,explain: ..� <br /> a � <br /> n (� <br /> c Application: pproved / Denied Reason for Denial: <br /> H <br /> Land Use: ! 9 Date: C <br /> '7 <br /> ' / ZONING <br />