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Burnett County Subdivision Permit Application Fees(must accompany form): <br /> and/or Pre-Application Form Subdivision w/o Survey: $10.00 <br /> Subdivision w/Survey:$100.00+$15.00/lot <br /> Owner. �2 S <br /> � a <br /> Address: <br /> / C 3 <br /> 1a7� s�e w 1 sw'y 3 Phone: �/J [a 3s��0 4 oz <br /> Orieinal Parcel Information <br /> Parcel Identification M 0 CO a� '0009ection o� Township `l 0/Range :/VW � <br /> Original Description(or attach copy): /i' Zoe �-N UJ <br /> O <br /> E <br /> e <br /> a u <br /> Current Zoning: 1 Floodplain Y/Pi Wetlands Y/}I: <br /> Lake/River Classification: Name of Water Body: <br /> New Parcel Information <br /> y�Proposed New Legal Description and Parcel Size: W I 0 (% _ 1/0� D U p <br /> _4-_ ISO t �{ U � S t�(L a � �n�vis ,0 L/0 At /1�2�. <br /> Z/_k11 C -/� CC) djL) CY\_CQ <br /> (/V Acres: "'Wo Q <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/N: <br /> If yes, describe access: <br /> d <br /> d <br /> A <br /> Signature of Owner: Date: D <br /> e ➢ DoesparcelmeeL ing Requirements? Yes No <br /> 0 <br /> ➢ Does parcel require a Survey? Yes No J <br /> ➢ Permit application fees submitted? ❑ Amount$ /0- D U Receipt# C� <br /> s <br /> e <br /> r ❑ Reconciles with Real Property Liste Yes No Date: G <br /> e <br /> a x <br /> ;c If not,explain: <br /> 0 <br /> N <br /> W <br /> Application:�,Approve51' / Denied Reason for Denial: <br /> i <br /> Land Use: <br /> Date: � <br />