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Fees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey', $50.00 <br /> Application and/or Pre-Application Form Survey of Existing Parcel: 0 .00+$5 <br /> /' //�� /j /� Q Pp Subdivision w/Survey: $200.00+$SO.ODAot <br /> Owner: LED '17 ( A086 / S Buy ., <br /> Address: 3q 71.5 Q ACU GTVe Address: <br /> Phone: - v [�//O Phone: <br /> 07-020-1-YQ-/b ' /9-5 16 ina Parce n ormation <br /> 7 ,/ / <br /> Parcel ID q:d'I-6Zp -Z-Yd /Ei -/q-g 1r-3b0 16 �Tawnship�ly Range�C <br /> Original Description(or attach copy): LL ' LU r 5 � 3- '26 151mele e <br /> 7"hA Ct�eSfi' 200 T7- 7L� / 12 <br /> o�u iV/5 .07 2L, — � <br /> Current Zoning:JLFloodplait(�/N: v Wetland Y Lake/River Class: <br /> 4 <br /> 9 Name of Water Body: (tllJl A Q Shoreland Agreement/SIPS Y/l6'� <br /> Farmland Preservation Y Managed Forestry Lax Y u <br /> New Parcel Information yn <br /> Proposed New Legal Description and Parcel Size: sm1 �Q <br /> Acres: -5, 6 L <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: PAI L 5 MCEE t7 <br /> Proposed access to public waters to be provided Yt!S)- !? <br /> If yes,describe access: 91 3 �3 <br /> Ga O <br /> Signature of Owner: Date: o� <br /> i v <br /> Signature of Owner: Date: n 9 <br /> oQS <br /> ➢ Does parcel meet Zoning Requirements? Yes No ° 1 <br /> ° D Does parcel require aSurvey? <-:Yes No <br /> s� <br /> tro 1 <br /> Permit application fees submitted? ❑ Amount$ Receipt N I�1 <br /> i <br /> ❑ Reconciles with Real Property Lister Yes No Date: U <br /> Wt <br /> ° If not,explain: �U <br /> Application: Approved Denied Reason for Denial: p q <br /> Land Use: <br /> Date:. -3�".�� G 4�7 <br />