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Fees Inst accompany form) <br /> Burnett County SubdiY•ision Permit Application Sum%,sionwioSunec s50.0o <br /> Survey of Emstmg Parcel $50.001w <br /> and/or Pre-Application Form Suldn,sionw•tSurvev Ss20000+s50.001ot <br /> Owner: ��ki w l/1 • /,0&1 47 Gk"&' Ii dl-'061 4' 4164 -1 Q f t`AP,6 .p <br /> Ave, C /l i II n <br /> Address: 1 �lPt.��o.v AS Address: jr0i(Q ! LItN0A .l`1rvL <br /> :. <br /> i n n _r. O r,f 5411 Zf ya - e�1; n v�a c�Aii tG5 M41 SSNl I <br /> Phone: Phone: <br /> c7•c 3,2 W-/(r-Ji-s /5-33/-"JYgCC <br /> t s 3S/ Ori¢tnal Parcel Information <br /> Zr <br /> Parcel lD#: e7•e•32--2- Set-gyp-.X-y 03-ery-C/1c+M- Section-12--TOvrnshi q Range <br /> _ O <br /> Original Description(or attach copy): � B 01 t? POT o <br /> �C)X2 .Ulu S/U -5 ,L YG S 0LV! n de=Pk C IV 01,ruek 62 d <br /> Current Zoning:A Floodplain YN:__L_YY'etlands Y'/N: oL' Lake/River Class: <br /> '' ll�y �� <br /> ^y Name of Water Body:_M-t r f �-c�-FS f va P_l C'te�en k Shoreland Agreement/SIPS Y' ' � <br /> a <br /> Farmland Preservation Y'N: AJ Managed Forestry Law YN: <br /> !view-Parcel Information <br /> Proposed New Legal Description and Parcel Size: n F.c, 5 ih <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 /> A <br /> Proposed access to public waters to be provided YN: <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: 3 <br /> - — C <br /> e <br /> i Does parcel meet Zoning Requirements? fes No <br /> Does parcel require a Sunry" 3'es No <br /> 7° P Permit application fees submitted.' amount 5a�)-00 Receipt rr <br /> ❑ Reconciles with Real Property Lister Y'es No Date: <br /> n <br /> 0 <br /> a <br /> If not,explain: <br /> M <br /> RIN <br /> 0 <br /> a <br /> N <br /> Applicata .( Approved-1 Denied Reason for Denial: 201 <br /> L;OUNLand Use Date 7rYauTM <br />