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Fees(must accompany form): <br /> Burnett Count' Subdivision Permit Application Subdivision w/oSurvey: $50.00 <br /> Survey of Existing ParceC S50'00lot <br /> and/or Pre-Application Form subdivision w/smvc�: $200.00+-S50.004ot <br /> Owner: 1 �'z'z4 i J c. r L r -67�ct 6�Y`+i,j Buyer: �' ��- Zr• <br /> Address 2,q,tP,'`,7 Address: �. fi '�� P11. <br /> Phone: )�� e7.` . Phone: <br /> Original Parcel Information <br /> Parcel ID#: , <br /> (yY�-('j .���.-�a -i�" Section-2 Township Range / <br /> 0.1-000 C U V 1 <br /> Original Description(or attach copy): R <br /> .o Current Zoning:[=[.> Floodplain Y(N:_ _Wetlands Y/N:_ Lake/River Class: <br /> c <br /> � Name of Water Body: Shoreland Agreement/SIPS Y/N: <br /> a <br /> Farmland Preservation YIN: '�� Managed Forestry Law YIN: 9,�} <br /> New Parcel Information <br /> .y^ 5 �'' / � ( L a v " ,7 <br /> Proposed New Legal Description and Parcel Size:�_r�'tf,� llltil(] )E � Y 5.� !�" f .1�`Y <br /> OG) ^ �"r 7<LtC Acres: l <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposedaccess to public road: C,.f o <br /> s <br /> A <br /> Proposed access to public waters to be provided Y{N:�� <br /> If yes,describe access: <br /> Signature of Owner: Date:4�2 <br /> Q— �Cy— <br /> Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning RequiremenRs? Y No <br /> Does pop-eel require a Storey? Yes \ .Vo <br /> 0° Y Permit applicationfee.s,submitted? ❑ Amount$ ReceiptN _ 1 <br /> O (qs <br /> 1.. ❑ Reconciles with Real Property Lister Yes No Date: <br /> y <br /> O <br /> franc,explain: 4. <br /> n <br /> o � <br /> o• _ `L <br /> Application. Approved / cried Reason for Denial: 0 <br /> Land Use. Date: <br />