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Fees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Application and/or Pre Application Form Subdivisionw/Survev: $200.00+550.00/lot <br /> �4olP <br /> Owner: SIA L I (} 1 E2 LE buyer oe-m N 1 5 SN Afiz-'.s r— I b <br /> Address: Z7'6h ALOQJ Rom Address: 2 LOEN e6AJ y <br /> 1{}ek ter, Illl ��t8`l3 <br /> W, ebl1-er W 15N8ti3 <br /> Phone: Phone: <br /> 315- 8bb- 5326 <br /> 15_ZgZ OrieinalParcelInformation <br /> p p <br /> Parcel ID#:�67-b 1Z-Z'y0-15-2g-2 6�f-ODb OS"o0o ;2d ection Townshi Range /514 <br /> AlO <br /> Original Description(or attach copy): E �Z 5-E Al /v W L X 66d' /f` -5 f460 <br /> F Lf No ' <br /> Al 660of 51o6o ' of E L1'16' 6F sE AjU/ <br /> Current Zoning: Floodplain Y&—Wetlands Y ]�: Lake/River Class: <br /> Y Name of Water Body: —' Shoreland Agreement/SIPS Y(S) (� <br /> �o <br /> Farmland Preservation YA Managed Forestry Law Y <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: �^/5 m ` �` `t I I 'I � <br /> Acres: O• V 6 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y o' <br /> If yes,describe access: w <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: <br /> d <br /> 9 <br /> C <br /> i Does parcel meet Zoning Requirements? Yes No z <br /> a <br /> e ➢ Does parcel require a Survey? Yes No <br /> 0 <br /> 0 <br /> °Q Permit application fees submitted? ❑ Amount$ Receipt# <br /> r., ❑ Reconciles with Real Property Lister Yes No Date: <br /> m <br /> 0 <br /> If not,explain: <br /> m <br /> n <br /> 0 <br /> a <br /> m <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />