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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> ot <br /> and/or Pre-Application Form Survey sionof w Survercel: 00.00$50.0 S <br /> SubdivisionwlSurvev: $200.00+$SO.00IIo[ <br /> Owner: �LM1-J\rIN�E G/yIC..K�'(J� Buyer: .y <br /> / n <br /> Address: a 61 /p�5 D LD HW Y ,3-? Address: <br /> t r���7-EkGu i ayg93 // <br /> Phone: 10-966- 8666 0 //�� //6ne: m 1?466 ` yga'5 W <br /> 33 ZS_ 0a3 Ori finallParcel Information . / <br /> Pa reel lD#: F t'J1 O 3'3 a S— O 2(400 , -Seection c99 <br /> Township ' /plei Range O <br /> Original Description(or attach copy): Al VV c W <br /> a <br /> 'O A <br /> Current Zoning: C 1Z P-2- Floodplain Wetlands Y& <br /> ro <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N:_Managed Forestry Law Y/N:_ <br /> New Parcel Information o- <br /> 3 <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: I C 2oh �J p <br /> A <br /> Proposed access to public waters to be provided Y/N: <br /> Q11- <br /> If ves,describe access: _ <br /> a <br /> e Signature o weer: Date: _6� r a-7 09 J) <br /> 0 <br /> Signature of Owner: Date: <br /> 0 <br /> ➢ Does parcel meet Zoning Requirements? Yes ' No 3� <br /> ➢ Does parcel require a Survey? Yes No C <br /> a � — <br /> Permit application fees submitted? ❑ Amount S 1-/06 , 0 b Receipt# <br /> n W <br /> a / wN <br /> 11 Reconciles with Real Property Lister Yes No Date: d,� <br /> d o <br /> If not,explain: 9 U <br /> Gc <br /> C C <br /> Applic . Ap r Denied Reason for Denial: <br /> Land Use: Date: VV/—CD <br />