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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: �,LA..,III��tC(zAAD0I- 1, 4eemuyer: <br /> Address: 9� 11140[J Ave- F Address: 3 <br /> MA! 3 <br /> Phone: 6 - (32 -O u Phone: <br /> OriEdnal Parcel Information ty, <br /> ParcelID#: �1z yZZS�V� StiZ Section 7S Township �O Range <br /> O <br /> Original Description (or attach copy): <br /> Current Zoning: r^ Floodplain Y& Wetlands Y 1V: <br /> Lake/River Classification: Name of Water Body: c r SAI-410 <br /> Shoreland Aar emt or SIPS Y/N: ? Farmland Preservation YC Mana¢ed Forestry Law /N: <br /> New Parcel Information r y�1/ <br /> Proposed New Legal Description and Parcel Size: 0-5 I , " t <br /> r\4� CS t r e -- AVS <br /> I h wVv Acres: 0. 76 <br /> (If parcel is to a surveyed,pro/ide preliminary map. See attached for preliminary <br /> map requirements.) <br /> Proposed access to public road: L <br /> i m <br /> Proposed access to public waters to be provided Y& <br /> If ves,descri a access: � <br /> N Signature of Owner: Date: <br /> e I <br /> Signature of Ow er: Date: o <br /> B <br /> Doesparcel eet Zoning Requirements? Yes No <br /> t ➢ Does parcel equire a Survey? Yes No <br /> a �( <br /> ,pro D Permit appli ation fees submitted? ❑ Amount S Receipt# <br /> n' ❑ Reconciles wi It Real Property Lister Yes No Date: <br /> y If not,explain: <br /> U} <br /> Application: Approved / enied Reason for Denial: d <br /> Land Use: Date: �� <br />