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01/20/1994 08:29 17158664206 WAGNER SURVEYING PAGE 02 <br /> Burnett County Subdivision Permit Application Ftes(must a company form): <br /> and/or Pre-Application Form subdivision tSurve10 ry: $lo.00 <br /> pp Subdivision lSurvcy:5100.00 SI3.00/10t <br /> Owner. /lggW mAk(2qA N - fK koj Bffr3G-f <br /> Address: bSgj M• 76 1054 1324d JE 6(o-3H9-2YyF5 3 <br /> cliOM, Ull X1$92 61-��Nel A 55P�e: -755-(oa35 P <br /> 0 <br /> d��-3335-o5zoo Original Parcel Information <br /> Parcel Identification 0: 401$-3335- 65300 section3C5 Township 3fAl Range <br /> Original Description(or attach copy): LdT 16 2r-o/, qv f O <br /> > oL- <br /> a _ I <br /> CurreatZoving: UN FloodplaftdN: Wetlan <br /> Lake/River Claaaiflcation: Cr/t�J�J Name of Water Body: Q New Parcel Information <br /> Proposed New Legal Description and Parcel Size: <br /> Acres• l• l/ <br /> (If parcel Is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: 5T• r]D <br /> v <br /> Signorfure of Owner: -.. ^ ..g) Date:..6- - 7 "• <br /> 9 Regtdrements? Yes NO <br /> N <br /> o ➢ Dmv parcel require a Survey? Yes No n. <br /> o <br /> Permit applieationrees submitted? ❑ Amount$ Receipi 0 <br /> c <br /> ie <br /> a <br /> ❑RbconeBes with Real Property Lister Yes No Date: <br /> 6 <br /> If not,sapMin: <br /> Appflesitba: Approved / Denied Reason for Denlai: <br /> Land Ueo: Date: <br />