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Fees(must accompany torm): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00dot <br /> and/or Pre <br /> }-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: ///l1� lL �/GLUY rJ I Buyer: y <br /> Address: /3�6�d75 2N4 IqvE IV Address: g <br /> Imo/✓AN t/�1U�4t 2 <br /> Phone: l I5- 6,56 J 156 J1 3 / Phone: <br /> 0'7-63z--z -yi/b z g-5 Original Parcel Information <br /> /�-W q- o#: yoao - <br /> DQ <br /> Parcel ID n N50G27 — U y6W6 Section 28 Townships YIAI/ Range /4 W O <br /> Original Description(or attach copy): E o�5 Z4-t 15 wr " <br /> A <br /> LvrS l -lSl bf B/K 3 PLA of Ofh giyeY <br /> �w N/= EX/577A/6 6/fiCCEL5 <br /> Current Zoning: (\k i Floodplain Y,O Wetlands V <br /> Lake/River Classification: '— Name of Water Body: 4 <br /> Shoreland Agreemt or SIPS Y&—Farmland Preservation 1& Managed Forestry Law Y(9 <br /> New Parcel Inforrmation� <br /> Proposed New Legal Description and Parcel Size: �� V • �• I 'l <br /> Acres: • <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: 1'i ILIA <br /> Proposed access to public waters to be provided Y/6 m <br /> If ves, describe access: <br /> Signature of Owner: Date: <br /> 1 ' <br /> Signature of Owner: �A� U C+ Date: <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ➢ Does parcel require a Survey? Yes No <br /> � J <br /> a0 T <br /> Permit application fees submitted? ❑ Amount$50C).Q V Receipt# <br /> A; <br /> ❑ Reconciles with Real Property Lister Yes No Date: t <br /> L <br /> If not,explain: <br /> e <br /> a <br /> N 1 <br /> Application, Approved / nied Reason for Denial: g <br /> Land Use: Date: <br /> o <br /> 0.0 Q o <br />