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Burnett County Subdivision Permit Application Fees(must accompany fonn): <br /> and/or Pre-Application Form Subdivision w/o Survey: $00000 <br /> /' pp Subdivision w/Survey:$I00.00+$15.00/lot <br /> Owner: F�wa vd //Q <br /> Address: A- Z1 <br /> / <br /> 00 t• 6Ut-L GG S��� C Phone: <br /> � <br /> Original Parcel Information ((� <br /> Parcel Identification#: Se e �Z Frac Ille Section Township Range <br /> Original Description(or attach copy): <br /> O <br /> 0 <br /> a <br /> q Current Zoning: de-P, IM- j Floodplain Y/N: WetlandsYIN: �� A <br /> o Lake/River Classification: Name of Water Body: <br /> New Parcel Information <br /> D <br /> Proposed New Legal Description and Parcel Size: ,� E' F q.-/�G 111'P':/ (� <br /> Acres: <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: C <br /> m <br /> A <br /> Signature of Owner: Date: OG O' <br /> o ➢ Does parcel meet Zoning Requirements? Yes No 17- <br /> > <br /> ➢ Does parcel require a Survey? Yes No J <br /> 0 <br /> Permit application fees submitted? ❑ Amount S I�)O.O() Receipt# <br /> •o <br /> e <br /> t ❑ Reconciles with Real Property Lister Yes No Date: <br /> 0 <br /> c � O <br /> ,y If not,explain: yj o <br /> 1 <br /> O G <br /> 9? <br /> Application: Approved enied Reason for Denial: o <br /> Q N <br /> Land Use: Date: <br /> 7 -2U- 07 <br /> e <br /> 0 <br /> C3 <br /> J <br /> O <br /> O <br />