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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 Subdivision w/Smvev: $200.00+$50.00/lot <br /> �C'4tAar dct r ret <br /> Owner: Su L 1 E M E2 LE gu3-er &-N N 1 5 pSN AIZ-5 K i <br /> LO <br /> QJ Z el$I A LN 1Z 0C(e-A Address: Z 7 g Z I t7 L O EN 1e6A <br /> Iueb�fi , I,11� aN8�3 1,U .ter, VV -5ygti3 <br /> Phone: Phone: 36-- b b— 5326 <br /> 9w vriEimalParcel Information <br /> Parcel ID#: Spec�tion a'g Township 94 <br /> / Range `J / <br /> Z 5t= NW LX Al6k' �I� ✓` 10 � o <br /> E <br /> Original Description(or attach copy): / � <br /> OF E �fy0 � <br /> Al 666 ' 6 F 51660 ' e E L816' o f 5E Al W <br /> Current Zoning: Floodplain Y.—Wetlands Y . Lake/River Class: <br /> ,o Name of Water Body: '— Shoreland Agreement/SIPS Y/.9:� <br /> Farmland Preservation Y16 Managed Forestry Law Y& <br /> T <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: C 6 m <br /> Acres: Ly <br /> (If parcel is to be surveyed,provide preliminary map. See attached <br /> for preliminary map requirements.) <br /> Proposed access to public road: <br /> n <br /> Proposed access to public waters to be provided Y6 <br /> If yes,describe access: <br /> Signature of Owner: `` Date: <br /> Signature of Owner: a"'� ^" 1""� Date: N�'2 201 <br /> c <br /> r Does parcel meet Zoning Requirements? es No n <br /> n <br /> N ?f <br /> 2 7 Does parcel require a Survey? C Yes No <br /> 0 <br /> PO ➢ Permit application fees submitted? ❑ Amount$ Receipt# <br /> r ❑ Reconciles with Real Property Lister Yes No Date: <br /> m <br /> c <br /> � If not,explain: <br /> n <br /> n <br /> 0 <br /> a <br /> y <br /> Applicata n: Approv d / Denied Reason for Denial: <br /> 41 <br /> Land Use: Date: c-�l - <br />