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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/tot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: �o.1J - flft NqN N StE��c Buyer: A <br /> B <br /> Address: \\\o0 C"-V-A 1A_ vla%.\ Gam. Address: z <br /> 51 e a� , `mN S 5\l q 2 696 SI�t 19 J! KOD <br /> Phone: Phone: <br /> 0260�� 611�1�,b�ltbyz OrieinalParcelInformation <br /> Pareel ID#: O\\o' 14-2-y' OI loo S Section-421--Townships—Range _ C <br /> n f <br /> Original Description(or attach copy): y <br /> A <br /> C__% � .2a w 131e- 13 Lof Io;i! a 'd L�lc 1z-IS <br /> y (P if pil.w� s <br /> q J <br /> R Current Zoning: UP Z•n�4 Floodplain Y� Wetlands�iN: <br /> c <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y& Farmland Preservation Y,4I =Managed Forestry Law Y&.= <br /> New Parcel Information G <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: ?� <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Ex i t 1 d <br /> A <br /> Proposed access to public waters to be provided Y& <br /> If yes,describe access: G <br /> C7 <br /> e Signature of Owner: Date: OCZ <br /> e <br /> n <br /> Date: <br /> °Q Signature of Owner: 3 <br /> c <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> u <br /> ➢ Does parcel require a Survey? Yes No o Q o 0 0 0 <br /> an �6`6' cf � <br /> Permit application fees submitted? ❑ Amount$ D D Receipt# <br /> w <br /> .c. <br /> o vw ww9� � <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> 1 <br /> 0 <br /> If not,explain: 1; o <br /> q,-VSs6 <br /> V Q <br /> Y <br /> Q <br /> Applicati A enied Reason for Denial: <br /> Land UsDate: 3` 3 _Q <br />