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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> and/or Pre-Application Form Survey of Existing parcel: $50.00/lot <br /> T t PP Subdivision w/Survev: $2000..000+�$50.00/lot <br /> Owner: <br /> APE Buyer: <br /> � O/� � D Q 6 A <br /> Address: 39 GXKaN 464e- A/-Address:, /0, 9X 7`q v2,1 B <br /> Sri�colsr,c /�.r/ sroSa /YI�40/so.-. W1 S-9 7a7-X;21 <br /> , <br /> Phone: 3 t — �� Phone: - 26 7-- 06749 <br /> ' <br /> / 0sinal Parcel Information eweV <br /> Parcel ID#; ✓S�� 3 JG U / J <br /> `1 Section j0 Township 3� Range44 <br /> _ <br /> Original Description(oratta}—z S' <br /> oJb - 2130 - DIS 0 <br /> e Current Zoning: _A a Floodplain Y/N: Wetlands Y/N: <br /> Lake/River Classification:CZL`F/1( Name of Water Body: <br /> Shoreland Agreemt or SIPS Y/N: Farmland Preservation Y/N: Managed Forestry Law Y/N:_ ( _ <br /> b <br /> New Parcel Inform`ationn <br /> Proposed New Legal Description and Parcel Size: �Mp Dnp o C4 <br /> Acres: <br /> Acres: oC9l i O <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: 330 lrt-� or,,, Ca <br /> m <br /> Proposed access to public waters to be provided Y/N: Y1� <br /> If ves, describe access: W�0 't�� GQ <br /> Signature of Owner: Date: / - (V�_dQeq <br /> Signature of Owner: Date: <br /> 0 <br /> 3 <br /> ➢ Does parcel meet Zoning Requirements? Yes No ° <br /> N m <br /> ➢ Does parcel require a Survey? Yes �_ No <br /> a°a O O <br /> { <br /> Permit application fees submitted? ❑ Amount$ 5_0 . �� R ceipt# o' <br /> 9J RI <br /> m 13Reconciles with Real Property Lister Y No Date: W W <br /> ° o d <br /> a <br /> If not,explain: p O <br /> i <br /> t1 G <br /> O <br /> Applicat' : Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />