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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 wlSurvev: $200.00+$50.00not <br /> a le <br /> Owner: i d . `JCLyLi 5A Buyer: ,y <br /> Address: I�3b � C�a )Cd F Address: 3 <br /> Phone: Phone: <br /> Orieinal Parcel Information <br /> Parcel ID#: 67 Q -YUN - 6 500 Section / Township 39/V Range H ✓V 1 <br /> O <br /> Original Description(or attach copy): Al W .50 <br /> "R?13 0 <br /> Current Zoning: Floodplain Y&It Wetlands YQ <br /> Lake/River Classification: Name of Water Body: <br /> Q <br /> Shoreland Agreemt or SIPS Y N_Farmland Preservation Y&____managed Forestry Law Y�_ <br /> C^ <br /> New Parcel IInformation :5-- <br /> Proposed <br /> Proposed New Legal Description and Parcel Size: C i <br /> Acres: J DCS <br /> (If parcel is to be surveyed,provide preliminary map. Seeattachedfor preliminary map requirements.) <br /> Proposed access to public road: CO Q T t7 <br /> m <br /> Proposed access to public waters to be provided Y6 g <br /> If Yes,describe access: / '1 <br /> e Signature of Owner: ` Date: <br /> o _ C>a <br /> Signature of Owner: Date: <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> m ➢ Does parcel require a Survey? Yes No O <br /> Z D Permit application fees submitted? ❑ Amount$D f5�' d C) Receipt# i 3,9 C7 0 <br /> n <br /> � W <br /> a ❑ Reconciles with Real Property Lister Yes No Date: p <br /> If not,explain: Q <br /> 4� <br /> �a <br /> Application• Approved eniedd Reason for Denial: v <br /> Land Use ��i�e�i Date: mss' O <br />