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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: $50.00/1ot <br /> and/or Pre-Application Form Subdivision w/Survey: $200.00+$50.00/lot <br /> Owner: <br /> p�Q/Y( /� / Buyer: <br /> Q � <br /> y <br /> Address: / . �. o X % G(O Address: 3 <br /> Phone: �IJ"�79 ZZZ� Phone: <br /> r/ Ori incl Parcel Inform ti 00 <br /> Parcel ID#: I –d/;Z–Z' �d 15-Z7 Z'dg <br /> i �ion Township QN Range K O <br /> f <br /> 0 <br /> Original Description(or attach copy): /V(AI /V M/ ; <br /> a <br /> m <br /> '- Current Zoning: f'/ C�— Floodplain)& Wetlands 166). (I� <br /> Lake/River Classification: Name of Water Body: <br /> New Parcel Information / <br /> Proposed New Legal Description and Parcel Size: J� (/ . 1 (XZa Dlf) <br /> Acres: <br /> 500 \ <br /> O <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) 1 <br /> Proposed access to public road: <br /> t7 I <br /> Proposed access to public waters to be provided A 9 <br /> If yes, describe access: <br /> o Signature of Owner: m' Date: <br /> o I <br /> e <br /> 00 Signature of Owner: Date: c <br /> 3 <br /> �1 9 <br /> ➢ Does parcel meet Zoning Requirements? Yes No –o fib Oek Qe�e(apm�fi S ° <br /> A <br /> parcel require a Survey? � <br /> ➢ Does ..rw <br /> p q ey.? Yes No may'do a O <br /> Permit application fees submitted? ® Amount$ t)5n.00 Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: v <br /> If not,explain: <br /> C5 <br /> Applicatio Approved Denied Reason for Denial: <br /> Land Use: Date: (::P 5- <br /> �a <br />