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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 cionof /Sure v: $ 0.00 S5 <br /> Subdivisionw/Survey: $200.00+$50.00/lot <br /> Owner: t t o N r .D Bore" kz 4 141 t.L. y <br /> Address: Address: Z'1 3 6 2 G'b N lti) 2p }� <br /> $�oer,3 2 !SAA93 <br /> Phone: Phone: <br /> Original Parcel Information <br /> � Z�4 i33� 'Z�soo <br /> Parcel ID#: p 2 g Wil- 1 9,3,0 2 S'DO Section S 3j Township X1-6 Range <br /> Original Description(or attach copy): /kY(ACFt GD a <br /> ;s <br /> a Current Zoning: Floodplain Y/N: Wetlands Y/N: PJ Lake/River Class: IJA� <br /> v <br /> Name of Water Body: Shoreland Agreement/SIPS Y N <br /> rt Farmland Preservation Y Managed Forestry Law <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: T-1i0 L-0-1— <br /> ": <br /> .oT": L07- -2- a Co A. <br /> Acres: 4-0 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: a-r)4 I+ k7U $o t<, TZD d <br /> Proposed access to public waters to be provided Y/N: �j <br /> If yes,describe access: <br /> 7 <br /> Signature of Owner: �• j 0t1 y1r<th,9 <br /> Date: ry` U' <br /> Signature of Owner: Date: �'��' <br /> 3 <br /> / F <br /> ➢ Does parcel meet Zoning Aquirements? l�Yes` No <br /> d ➢ Does parcel require a Survey? Yes No <br /> °4 ➢ Permit application fees submitted? ❑ Amount S / ' Receipt# <br /> r ❑Reconciles with Real Property Lister Yes No Date: <br /> m <br /> p <br /> °' If not,explain: <br /> 7y <br /> 0 <br /> R <br /> d <br /> H <br /> Applicatio A�pp)rove Denied Reason for Denial: <br /> Land Use: <br />