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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 /> and/or Pre-Application Form Subdivision wt Survev: $200.00+$50.00/lot <br /> Owner: //��SL�.- � � //���— Buyer: <br /> Address: • (),a7�) 2n'd htIE IV Address: 3 <br /> Phone: l " IU Xi .� �J U Phone: <br /> 0'763l Z -7/(& l y-> Original Parcel Information <br /> 15 coq_ OySlaov — �� <br /> Parcel ID#: �� 4 jC60 C)y& LG 'dV*A61 U Section 2-8Township /I� Range O <br /> Original Description(or attach copy): L -`� C 0 t /!5) <br /> Current Zoning: ���L Floodplain Y,�'•/ Wetlands <br /> Lake/River Classification: Name of Water Body: -- <br /> Shoreland Agreemt or SIPS Y&-i Farmland Preservation VS-_Managed Forestry Law Y& <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: �y+ m <br /> VA. Acres: < ( & <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: f 1 ib.X U T d <br /> Proposed access to public waters to be provided Y/6 <br /> If ves,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: B <br /> ➢ Does parcel meet Zoning Requirements? Ye No <br /> Sac UU�r� <br /> 2 ➢ Does parcel require a Survey? Yes No <br /> o' <br /> ao <br /> Permit application fees submitted? ❑ Amount$ Receipt# <br /> r ❑ Reconciles with Real Property Lister Yes No Date: <br /> m <br /> e <br /> a <br /> R: If not,explain: <br /> n <br /> n <br /> O <br /> 1 <br /> d <br /> N <br /> Applica 'on: Approve Denied Reason for Denial: <br /> af7r� 0r ."Ni-16 <br /> Date: <br /> Land Use: fP �tJ <br />