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p - Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: 850.00 <br /> and/or Pre-ApplieatiolnForm Surveysion of /iurvev:ng el: 850,00/lot <br /> �'` /� Subdivision w/Survey: $2>)O.00+S50.00/IotW' <br /> Owner: tit cS f! �QV#-4 k Ac CGvi Buyer: <br /> A <br /> Address: 52Address: 5 <br /> DQA��ry W- S483o z <br /> Phone: 71.s'S(o( - Phone: <br /> Original Parcel Information <br /> Parcel lD#: 012. 4219-01 - 200 Section f$ Township 4b Range IS <br /> �+ O <br /> Original Description (or attach copy): SSL e�28 �/A07 60-1 400 <br /> -- ,5ybd;,ay-A VQv(AAce 2011) Aeer y , <br /> Current Zoning: Rf, ( Floodplain(�N: Wetlands <br /> 'YMo <br /> Lake/River Classification: Z Name of Water Body: Nd n. Z4&r <br /> Shoreland Agreemt or SIPS Y/N:_Farmland Preservation Y&_Managed Forestry Law Y6_ <br /> New Parcel Information / <br /> Proposed New Legal Description and Parcel Size: CS-M V/` a� <br /> Acres: <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(9 o <br /> If yes,describe access: wYkL { porCG <br /> c Signature of Owner: WY'v e4/ /✓L Date: <br /> 0 <br /> Signature of Owner: Date: 0 1 <br /> c <br /> ➢ Does parcel meet Zoning Requirements? es YNo /(�� 'rc' <br /> �q� v cf-tt•l,la � \t� <br /> a ➢ Does parcel require a Survey? No d <br /> G as I <br /> Permit application fees submitted? L� Amount 3 Receipt# 1 <br /> a 1 <br /> ❑ Reconciles with Real Property Lister Yes No Date: Oo � <br /> I <br /> If not,explain: d <br /> Q <br /> Application: Approve / Denied Reason for Denial: <br /> Land Use: Date: 9-1 <br />