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Fees(must accompany forth): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey: $50.00 <br /> Survey of Exisfing Parcel: $50.00/lot <br /> Application and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: S C.1 Buyer: y <br /> A <br /> Address: Address: <br /> Phone: -7 I SE L4 I I? - 2-4:' ,0 Phone: <br /> bag-y/a x_01- C-C) Orieinal Parcel Information <br /> Section <br /> ParcelID#: 1 —j)A— —7D'I 011001 _2LTownship 40 Rangej4— <br /> Original Description(or attach copy): <br /> S <br /> Current Zoning&__jF/loodplain Y Wetlands YLake/River Class: <br /> ,e Name of Water Body: /V / Shoreland Agreement/SIPS Y2 <br /> q <br /> F Farmland Preservation Y Managed Forestry Law <br /> 0 <br /> New Parcel Informationn� <br /> Proposed New Legal Description and Parcel Size: h IYAG v`SIn <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: ��I �-_V] cid d <br /> Proposed access to public waters to be provided <br /> If yes,describe access: l/ <br /> i <br /> Signature of Owner: Date: T�7 7 <br /> Signature of Owner: 0 Date: 3 <br /> Does parcel meet Zoning Requirements? Yes No n <br /> a <br /> Does parcel require a Survey? Yes No C�) <br /> S2) <br /> ➢ Permit application fees submitted? ❑ Amount s Qb Q ' 0 O Receipt# Op <br /> 1 <br /> r. ❑ Reconciles with Real Property Lister Yes No Date: <br /> e R) <br /> a' If not,explain: I <br /> �0 Q <br /> e ppI1 <br /> V <br /> Application:CApproved Denied Reason for Denial: VG <br /> 42 1 <br /> Land Use: Date: 21 J i4> .20 1( <br />