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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 /> �( <br /> and/or Pre-Application Form Subdivisionnw/Survev, $200.00+$50.00Aot <br /> Owner: eajAe/me- 7e-mAK �/ / Buyer: �.4!th <br /> Address: R 0 (.�es�M /J�e A,'#T41s Address: /al 41 1Q0h PV+S Qat <br /> S//�. PmAt 4 A11V✓ 15IT z s0 06-A Pr <br /> Phone: t0-S( - �/ / ' / b r� Phone: -� <br /> Or inaI Parcel Information S1� <br /> p '7-028 -2-Yo-IV- 21( 0)— Q0zr <br /> ParcellD#: 0'1-028,2-y0-t°f'ZY- 5 df-Ov-ozcsection�Township A Range <br /> 2 13W <br /> Original Description(or attach copy): LOT lP� LSM 2/, VolIl 6 $0 <br /> !�R 29d <br /> s Current Zoning: Floodplain YIN: D Wetlands Y/N:_ /Y • Lake/River Class: <br /> c ]' <br /> n Name of Water Body: dn(fh� Shoreland Agreement/SIPS V/N: <br /> e - I <br /> Farmland Preservation Y/N: /y 0 Managed Forestry Law Y/NA- /0— ^ <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: <br /> ntEu/ LSW Lo fs G t 7 � <br /> o f I3 • L( acres f 5.04 arret .4 reSlie�yclN <br /> Acres: /3•2./ ; 5-016 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: FX 15 I O <br /> m <br /> A <br /> Proposed access to public waters to be provided Y/N: tvo <br /> If yes,describe access: S <br /> t <br /> Signature of Owner: Date: O <br /> Signature of Owner: 1 C -A G,a Date: OVA ` l <br /> R <br /> l; 3 <br /> a <br /> ➢ Does parcel meet Zoning Requirements? YNo Noe S n yr d (C A <br /> e1 0 `t-t0 Y T,Does parcel require a Survey? Yes No �t-- O?pO <br /> wQ <br /> D Permit application fees submitted? 11 Amount$,3001 0 Receipt# �?O <br /> ❑ Reconciles with Real Property Lister Yes No Date: 9) <br /> m �L <br /> o � , <br /> If not,explain: C O <br /> a t7 0 <br /> Applic Approved Denied Reason for Denial: H <br /> l Land Use: Date: <br />