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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> and/or Pre-A licatlon Form Survey of Existing Parcel: $50.00/lot <br /> pp Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: _� C HA2 OCZ— Buyer: <br /> q b <br /> Address: 4� I s'j`'q�e. a. �04,D Address: <br /> I�'� <br /> VF>56tJ �� s4011; o <br /> i <br /> Phone: /S 2 ,67 Phone: (A) <br /> Original Parcel Information <br /> Parcel ID#: OSection I Township ' / Range 1 T <br /> O <br /> Original Description(or attach copy): G r c t V Lei 0 <br /> \J0 k_ Z I J, Low <br /> a (Z3 <br /> 10 <br /> �j r7 q j <br /> A <br /> e Current Zoning: !`2 J Floodplain Y/N: _�1 T 1 +—Wetlands Y/N: J / <br /> Lake/River Classification: Name of Water Body: L l PS N l,�tk_� <br /> Moreland Aareemt or SIPS Y/N: Farmland Preservation Y/N: Manaeed Forestry Law Y/N: <br /> 13Q <br /> New Parcel Information <br /> ii11 /^ n <br /> Proposed New Legal Description and Parcel Size: Iv T� �If2y�� <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C <br /> m <br /> Proposed access to public waters to be provided Y/N: A <br /> Q <br /> If Ves,describe access: ,Nt II <br /> N Signature of Owner: Iv i Sl -^ Rkv Date: <br /> o � <br /> v Op <br /> Signature of Owner: Date: c <br /> a <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> m <br /> m ➢ Does parcel require a Survey? Yes No a <br /> CL O <br /> �7J ➢ Permit application fees submitted? ❑ Amount$ ' 0 Receipt# 4J <br /> o � <br /> 5 <br /> y ❑Reconciles with Real Property Lister Yes No Date: (,V <br /> If not,explain: <br /> Q <br /> ,-C <br /> Applicatio Approved / enied Reason for Denial: G <br /> Land Use: v Date: 9 �� 0 9 <br />