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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/lot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: a �� Buyer: .,y <br /> Address: I qO I OCL K Address: B <br /> S/U'u Lbl, Wt arIlm) <br /> Phone: hone: .4-- <br /> 0 <br /> ParcelInformation / <br /> Parcel ID#: bO b I ICi- I Z(i Section M Township 31p1/V Range 0 <br /> Original Description (or attach copy): /VC 4 <br /> Current Zoning: L40 Zo,y? /I Floodplain N Wetlands Ye..) <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPSY Farmland Preservation Ye Managed Forestry Law <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: L6 5�L <br /> Acres: 5.00 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: OCC Af �t5 C7 <br /> m <br /> Proposed access to public waters to be provided Y/ <br /> If yes,describe access: c <br /> SU <br /> o kignature of Owner: O. /' 11— �jp <br /> , _ Date:� d t— -Ui <br /> 0 <br /> °Q Signature of Owner: Date: B <br /> D Does parcel meet Zoning Requirements? Yes No O�1 u <br /> D Does parcel require a Survey? Yes No �� t <br /> y �l <br /> C3 <br /> Permit application fees submitted? ❑ Amount$ Receipt# <br /> 0 1 <br /> a w <br /> ❑ Reconciles with Real Property Lister Yes No Date: _ <br /> O <br /> If not,explain: o <br /> P <br /> Q <br /> Applicatio Approved / Denied Reason for Denial: / r/ <br /> Land Use: Date: �/ —O <br />