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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Snbdldsion w/n S.,c,: $50,00 <br /> Survey of Existing Parcel: 550.00/lot <br /> and/or Pre-Application Form or Map Review Form Subdivision �Snrve, $200.00=$so.00nnt <br /> / V <br /> Owner: (� )PINZ-1 l a E".....Q �/. 4 <br /> Address: S-0 R �. L C± Address: -C c <br /> Sz2Yr <br /> k � <br /> Phone: �J )� 3 czs-� S) Phone: <br /> / Original Parcel Information <br /> Parcel ID#: �b L B 6 7 Sectionci�Taw nshi Range/ n <br /> Original Description(or attach copy): <br /> �C <br /> Curren[Zoning: RR_D, Floodplain Y/N:�1 o Wetlands YN: Lake/River Class:_ <br /> .o Name of Water Body: �„l�e L r Shoreland Agreement/SIPS Yo <br /> L '1 <br /> -n Farmland Preservation Y/N: N'D Mhlanaged Forestry Law YIN: IST <br /> a <br /> New Parcel Information V, <br /> Proposed New Legal Description and Parcel Size: �J>�1�\, f"p <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> m <br /> Proposed access to public road <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: ) <br /> Signature of Owner: Date: IQ/ 6 rl3 <br /> Signature of Owner: ' G(y-zt% [)are: /6 <br /> u <br /> i' Does parcel meet Zoning Reyui en(s? Yes No <br /> c i Daes parcel require n Sarver? Yes No <br /> a <br /> Permit applicationfeessubmitled% Amount$ �/�'co Receipt# <br /> ❑ Reconciles with Real Property Lister Yes No Date: C) <br /> b <br /> r b <br /> If not,explain: 1 <br /> a <br /> Application:: Ad / Denied Reason for Denial: <br /> \ <br /> Land Ilse: Q <br /> 1 <br />