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Fees(must accompany torm): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> E Survey of Existing Parcel: $50.00/lot <br /> and/or <br /> -Pre•-Application Form Subdivision w/Sutvev: $2 <br /> / 00.00+$50.00/lot <br /> Owner: L(,�/I C/ �l l bol / Buyer: �o rn 1AP--Z )V7A1 ,b <br /> Address _�lZyg NQ1rY(en 711 Address �a53 `/r � riL 3• <br /> ` z <br /> 7/,-a 59- 3�y� Phone: <br /> Phone: � � <br /> Original Parcel Information <br /> ParcelID #: g���7bNpy�� b3g� l�� Section_ Township 7�� Range /"✓ <br /> Original Description(or attach copy): Th (J L <br /> g <br /> /. lc-/c-�— C <br /> � Current Zoning: / Floodplain Y�I: Wetlands 16 <br /> Lake/River Classification: ! Name of Water Body: &1z" � (� <br /> Shoreland Agreemt or SIPS Y Farmland Preservation Yo---Managed Forestry Law Y6 t <br /> New Parcel Information'V. <br /> Proposed New Legal Description and Parcel Size: C 5 J V. Its I <br /> (07 R-Acres: b. <br /> (If parcel is to be surveyed,provide preliminary map. [[See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> w <br /> n <br /> Proposed access to public waters to be provided YIN: " <br /> If ves, describe access: i <br /> Signature of Owner: I q Date: 1 / <br /> Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning Requirements? Yes) No e` <br /> _. ➢ Does parcel require a Survey? Yes Na - g'g <br /> as <br /> Permit application fees submitted? ❑ Amount$30b, 0 (D Receipt# <br /> t ' <br /> ❑ Reconciles with Real Property Lister Yes No Date: - <br /> a <br /> M <br /> If not,explain: g <br /> 25 0 <br /> Application Approve / Denied Reason for Denial: d <br /> l�/ W <br /> Land Use: Date: �+ <br />