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Burnett County Subdivision Permit Application Fees(mus�'accompany form): <br /> and/or Pre-A lication Form Subdivisi w/o Survey: $10.00 <br /> PP Subdivisi w/Survey:$100.00+$15.00/1ot <br /> Owner: M1 1•'/lf��Gy p'Rw i' E/fl/e y p7^j3 Jaf//sY'L <br /> A <br /> Address: <br /> G1te&y CA4J-cAf9 201 T Phone: �j• 6-rt - fyy* e <br /> Orieinal Parcel Information <br /> E Tlo 620. 43!10.0(. 0 <br /> Parcel Identification#: 09&. 41to-D/.fovea Section ID Township 40 Range �( <br /> Original Description (or attach copy): Got,f z.+4 3 Gk« f 7 _C ' 0 <br /> a nl <br /> fC <br /> Current Zoning: Z Floodplain&N: c..Iikr Wetlands /N: Z4*y <br /> Lake/River Classification: 2 Name of Water Body: 44w< 4A,.e <br /> New Parcel Information <br /> N <br /> Proposed New Legal Description and Parcel Size: C—SM 2 C.-Ori <br /> A <br /> Acres: <br /> (If parcel is to be surveyed, provide preliminary map. See attached for preliminary ins a requirements.) <br /> Proposed access to public road: -V4 o W#t 9 o O1 Jf X* #. f 4 f rl <br /> �f d <br /> Signature of Applicant: �9" Date. 6I�/d <br /> i <br /> ➢ Does parcel meet Zoning Requireme s? Y No v <br /> p <br /> 0 <br /> �• ➢ Does parcel require a Survey? Yes No <br /> Permit application fees submitted? ❑ Amount S 13C)' U d Recei t# 6 S <br /> s <br /> e <br /> A <br /> r # <br /> � <br /> [I Reconciles with Real Property Lister Yes No Date: o <br /> a O <br /> 9 If not,explain: O <br /> w w <br /> o O <br /> ` p <br /> ApplicatioApprove / Denied Reason for Denial: C <br /> oLand Use: Date: � <br />