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Fees(must accompany form): <br /> • <br /> Burnett County Sub t Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> and/or re-Application F Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: FC 0 YOy oh N s6 r,J Buyer: ti <br /> A <br /> ? z <br /> Address: J m 1 NerUr1 Address: 3 <br /> QCLn..�ur�, GAJ- 5 �l K3 U <br /> Phone: 65(1 ` 7 10 y _ Phone: <br /> Ori¢inalllParcel Information <br /> Parcel ID#: 03 a - 5 33 (a -01 -fib V Section_3�0_Township L4 Range <br /> Original Description(or attach copy): <br /> A <br /> �l <br /> Current Zoning: �Floodplai�Y N: WetlandsN/N: Lake/River Class: l T <br /> a Name of Water Body: Orexi% L= Z_W// 2 Shoreland Agreement/SIPS Y9_ <br /> S <br /> R, Farmland Preservation YlY� Managed Forestry Law <br /> New Parcel Information J <br /> Proposed New Legal Description and Parcel Size: '3 �Yn 0+'S + <br /> l�eScr,fa±()Vim ('sly ✓,a� p, / <br /> Acres: 5.9- X71(o 'l+ <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: (�I` (}(SCE'`S Le -roL,)r inl`-0 Voti�a�� p <br /> Proposed access to public waters to be pro vided�Y/ : 2 <br /> r - )6+S <br /> If yes,describe access: p Lel p Uc- (.� Jer -Tro n Ct <br /> Signature of Owner: Date: .2 7— <br /> Signature <br /> Signature of Owner: Date: 3 <br /> 9 <br /> C <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ➢ Does parcel require a Survey? Yes No 34,7�'s IP7S'Phar 10 Ac.F' <br /> n O <br /> Q <br /> °0 ➢ Permit application fees submitted? ❑ Amount$367).O O Receipt# <br /> m ❑ Reconciles with Real Property Lister Yes No Date: LU <br /> � If not,explain: P <br /> o � <br /> a <br /> H Applicati Approved / enied Reason for Denial: <br /> _...,�e cJ J1eH1_1 <br /> Land Use: Date: <br /> Pf� lgllc,-7L ao ti ApProf) <br />