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Pees(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/Survev: $200.00+$50.00/lot <br /> Owner: g AM/uyer: ti <br /> Address: � /qfl Address: T <br /> Phone: 715-866- / / Phone: <br /> O7 o�Z'Z—yra /J-Z�Jr OricinaI Parcel Information <br /> 05-406— <br /> /2 O/9000 <br /> 65-005-40/9COO Section C6 Township Range <br /> /' O <br /> Original Description(or attach copy): G. L <br /> n <br /> k T <br /> Q c <br /> Current Zoning: ' / Floodplain Wetland] N' ': Lake/River Class: / <br /> e Name of Water Body: Shoreland Agreement/SIPS Y6 <br /> PC <br /> Farmland Preservation Y(LV'. Managed Forestry Law Y6 <br /> New Parcel Informatyio�n� <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: ✓• / v <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: D�2D d O Q <br /> Proposed access to public waters to be provided Y& O j <br /> _ S� C_ <br /> If yes,describe access: p t S9) <br /> (� � J = Su <br /> Signature of Owner: 1Date: - Q"�Z— t <br /> Signature of Owner: /1 Date: 1- 4 - / Z or o <br /> VIl U <br /> ➢ Does parcel meet Zoning Requirements? Yes No /C % JAS" m t <br /> o ➢ Does parcel require a Survey? Yes No t i <br /> d � <br /> 00 ➢ Permit application fees submitted? Amount$ lU / Receipt# Q <br /> r., ❑ Reconciles with Real Property Lister Yes No Date: tD O <br /> is <br /> If not,explain: <br /> o <br /> a OC <br /> O <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />