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Fees(�euata i fo <br /> Burnett County Subdivision Permit Application (sem ofnwExt/o grV sso.00na <br /> and/or Pre-Application Form Subdivision w/Swev: 5200.00+MAOU <br /> / t Q6, Jane, Arf4*e-1 <br /> Owner: ���� .T+ it%fQn1[l'� Buyer: 7� <br /> Address: 1711Z aj L".'(y a, / G h Address: B <br /> 2 <br /> C rro �a Falls w,17 SW7,27 <br /> Phone: 8 a g- W" Phone: <br /> Original Parcel Information <br /> Parcel iD# Tat�D <br /> 11799 Section a 3 Township/Range <br /> Original Description(or attach copy): <br /> pe,-, C S�p� �f7Glb5Crt RGA rK 7` <br /> o <br /> e <br /> Floodplain YM: Wetlands Y/N: <br /> .. Lake/River Classification: Name of Water Body: , N� <br /> Shoreland Agreemt or SIPS Y/N:�Farmland Preservation Y/N: N/ Managed Forestry Law Y/N: A <br /> New Parcel Information 9/ r Q <br /> Proposed New Legal Description and Parcel Size: Al Y2 OF '� e <br /> Acres: q or-P5 <br /> (If parcel is to be surveyed,provide preliminary map. Seeattached for preliminary map requirements.) <br /> Tc- l <br /> Proposed access to public road: ersq r\ t�/`9 a C d <br /> Proposed access to public waters to be provided Y/N: �_ J <br /> If Yes,describe access: <br /> Signature of Owner. !et ` Date• 7 Jr <br /> Signature of Owner: Date: 9 <br /> e <br /> ➢ Does parcel meet Zoning Requirements? _ Yi No T <br /> o <br /> 6. D Does parcel require a Survey? yes No <br /> Permit application fees submitted? ❑ Amount$ Receipt# l <br /> ❑Reconciles with Real Property Lister Yes No Date: _ (- <br /> e <br /> 6 1 <br /> If not,explain: <br /> 0 <br /> Application: tprov / Denied Ressou for Denial: �j O <br /> Land Use Date: <br />