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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 /> and/or LU <br /> Form Subdivision w/Survey $200.00+$50.00/lot <br /> Owner: 1l OI(}-[ LSA i/ I le_`�-rr iff Buyer: -0 <br /> N <br /> T Z <br /> Address: DI: Address: 3 <br /> Phone: Phone: Vi <br /> v <br /> Original Parcel Information <br /> Parcel ID#: -W — Section Township Range <br /> Original Description(or attach copy): <br /> A <br /> z <br /> a <br /> 9 Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: <br /> 9 <br /> Name of Water Body: Shoreland Agreement/SIPS YIN: <br /> .. Farmland Preservation YIN: Managed Forestry Law Y/N: <br /> New Parcel Information / y� <br /> Proposed New Legal Description and Parcel Size: 1 I 1 , ` I gD�/—�1.(,t <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: y <br /> m <br /> m <br /> Proposed access to public waters to be provided Y/N: � <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: c <br /> i3 <br /> 9 <br /> C <br /> ➢ <br /> Does parcel meet Zoning Requirements? Yes No re <br /> N ' <br /> °o ➢ Does parcel require a Survey? Yes No <br /> 0 <br /> r° ➢ Permit application fees submitted? Amount SJD .aD Receipt# <br /> r• ❑ Reconciles with Real Property Lister Yes No Date: <br /> d <br /> 0 <br /> o. If not,explain: <br /> m <br /> 0 <br /> a <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />