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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: 550.00/1ot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+550.00/lot <br /> Owner: /11V t A) 1170'Y/A5 -- A Z:4uyer: o <br /> Address: �$`� 3 �1 �2Q�1� 0(6V-'e-Address: J 6 L�C� <br /> &)06 bcu'y, /h/V 554-6 <br /> Phone: Phone: <br /> p <br /> Original Parcel Information / <br /> Parcel ID#: a� / / 0 7 9O U Section 19 ,7 Township / Range <br /> O <br /> Original Description(or attach copy): `�(tJ �G(J A <br /> 71 <br /> a <br /> 9 <br /> Current Zoning: 2 a11 Floodplain(I}N: Wetland(j)N: _ 3 <br /> Lake/River Classification: 7 4 I Name of Water Body: R061e — &4U1V61rmee y <br /> Shoreland Agreemt or SIPS '& Farmland Preservation Y&_Managed Forestry Law YAV_ <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: Gl3� <br /> Acres: 4 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> m <br /> Proposed access to public waters to be provided Y* A <br /> 6� <br /> If ves,describe access: <br /> O <br /> c Signature of Owner: _ Dat ✓y / ����,� <br /> °Q Signature of Owner: Date: <br /> 'CI <br /> ➢ Does parcel meet Zoning Requirements? ye No <br /> 7 — <br /> ➢ Does parcel require a Survey? Yes No O <br /> a r� <br /> Permit application fees submitted? ❑ Amount$oy' /b Receipt# <br /> o � <br /> a Cl) <br /> ^ ❑ Reconciles with Real Property Lister Yes No Date: Z <br /> If not,explain: <br /> O <br /> 0 <br /> Application Approv Denied Reason for Denial: d <br /> Land Use: �12 Dat "��G <br />