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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application SuMvisimw/oSurvey: $50.00 <br /> and/or Pre-A licatlon Form Survey of Existing parcel: S%00/jot <br /> pp Subdivisim w/Su.vev: 5200.00+550.00,1m <br /> Owner: ZgA4,tNcC .�FiNK�, /v2n�S0/fA1 Buyer: ,e <br /> Address: 3�3s� J/40I�} /IL //C Address: <br /> paU6��, w.z sy�r3o z <br /> 0 <br /> Phone: SIS•�G.'S�e 3 5- Phone: w <br /> l Orieinal Parcel Information ` <br /> Parcel ID#:�-5,7 -n12— Section QY' Townshie VIM Range IS-W• v�ll <br /> Original Description(or attach copy): See <br /> A <br /> R <br /> e Curren[Zoning: BR 3 Floodplain Y/N: N d Wetlands Y/N: Lake/River Class: N L <br /> C <br /> e Name of Water Body: Ve HC Shoreland Agrcement/SIPS YIN: Aid <br /> 4- <br /> Farmland Preservation YIN: Nd Managed Forestry Law Y/N• yeJ <br /> New Parcel Lnjormation <br /> Proposed New Legal Description and Parcel Size:_ ` <br /> . a - <br /> Acres:_ �Oj$ <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> + <br /> Proposed access to public road:_ 4&J'C r s.//— qc Ao35 12Ali v+-he_ /" A'?c�/4 d <br /> m <br /> Proposed access to public waters to be provided YIN: /HYD <br /> O d <br /> If yes,describe accts: t <br /> � <br /> Signature of Owner: iL�``�� Date- —L� 1',Q-yj� p 1 <br /> Signature of Owner. GL Date: �' _ L6'.-�/z) o <br /> e <br /> N ➢ Does parcel meet Zoning Requirements? es No 6(4—7Z � 4'ro R <br /> 'e ➢ Does parcel require a Survey? Yes No 1 <br /> o <br /> )01 <br /> °q Permit application fees submitted? ❑ Amount$ ,300• 00 D Receipt# <br /> i I <br /> m ❑Reconciles with Real Property Lister Yes No Date: p� <br /> o b <br /> If not,explain: Cfl <br /> n <br /> e <br /> R <br /> W <br /> Applicati : Approved / nied Reason for Denial: <br /> Land Use: Date: <br />