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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/lot <br /> I' <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: fA/�/I�L/I/prin /� r Buyer: A <br /> Address: / 3'7 016 �k d �lQ Address: E <br /> l Ylr//1nd,/7D✓� P <br /> 70- 6 %- <br /> 7 <br /> Phone: / I - 6 JF7—" / / / 1 Phone: j <br /> 1 7 / Original ParcelInformationQ� <br /> Parcel ID#: ��-53��/ V �GU Section o?9 Township 1 1N Range / <br /> O <br /> 141 <br /> Original Description (or attach copy): <br /> a <br /> Current Zoning: r ` �� Floodplain YQ Wetlands Y© <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y&Farmland Preservation Yo ...Managed Forestry Law Y4!S� c <br /> New Parcel Inffoo/rmation <br /> Proposed New Legal Description and Parcel Size: C <br /> 3 <br /> Acres: <br /> (If parcel is to be surveyed,providepreliminarymap. See attached forpreliminary map requirements.) <br /> Proposed access to public road: ac/ �G <br /> Proposed access to public waters to be provided Y® <br /> If yes,describe acces <br /> t <br /> e Signature of Owner; - Date: <br /> e <br /> Q0 Signature of Owner: Date: <br /> e <br /> ➢ Does parcel meet Zoning Requirements. Yes No <br /> ➢ Does parcel require a Survey? Yes No <br /> a n <br /> Permit application fees submitted? ❑ Amount$ aR)• 00 Receipt# /d O b 6 <br /> n <br /> o <br /> a <br /> y <br /> 11 Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: -p <br /> uJ <br /> a <br /> ApplicationApproved Denied Reason for Denial: Z p <br /> Land Use: Date: s ' ✓ a <br />