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Fee (�nus1 occompany fonng <br /> Burnett County Subdivision Permit/Survey Review SuWfvkton wn,S.,ev: ssual <br /> Survey of Es"It,Pard: 551100/101 <br /> Application and//or Pre-Application Form sahm.;,ioo wt sar�e�: rw.w a50 aural <br /> oenero ��/'/'4 F/;^' /V�Sa/�. Rayer: �f(�lC17 g 171'CPiC(/n k,2 j24 <br /> I Address l_/7(7y7 I�PP /S P' Address: 27.33 V" <br /> lle6s�e� W: 54 '93 Fore_ IM I55_0aS__ <br /> Phone: Phone: l0 <br /> Original Parcel Information d <br /> -07-0/b-Y39-0-03-/ 00-0e0-w'cr.)0 <br /> Parcel 11)9: p7 -0/601­al-q,ob(l Sectian 3 Township 341 Range /7 C <br /> Original Description (or attach cop)): <br /> j✓£I/� 3 Jac ,i z 4 ev +t yaw /7 <br /> Current Zoning: floodplain Y/N: _ „'ellands`yt,.: Lake/Rivcr Class: <br /> > Name of Water Rod.,: Shorcland Agreement/SIPS 1'.N'`: O <br /> 9 <br /> = Farmland Preservation Y�,J Managed Forestry Law <br /> New Parcel Information <br /> Proposed New Legal Deserip[iaa and Yarcel Size: <br /> /ti% o .� AIy� 0 f lk ti� YY <-_ <br /> 3 _ �o(✓ti39 _ anq� /7 <br /> — — — -- — <br /> �Acres "- ' <br /> ., (if parcel is to he surveyed,provide pr7liminury map. Sec attached for preliminary map reyuiremenk.) -- - <br /> Propowd access to public road: - - - -- - ^ <br /> c <br /> Proposed access to public waters to be provided Y/N: <br /> If yes,describe access: <br /> Signature of Owner: / V� Date: '>'—�l'�� , _1 <br /> —'Si,ok um of O:vncr, _W❑ _ <br /> i Does parcel meet Zoning Requiretnews? Yev Nn l]� l <br /> i Does parcel require a Surrey? Yes No p <br /> ' _O <br /> i PerrnitnpPlicntionfeesauAnlitted? ❑ A...now 5``Receipt#I�I'flR <br /> n ' I <br /> /❑ Reconciles with RealYroperty lister /YesI No Uale2lhl� <br /> c w <br /> A { If not,explain: - WO � <br /> --- - - G <br /> J <br /> Appli rmo r\permed / Denied Reason for Denial. -- -- ^ _- <br /> Land Use: Date' <br /> B <br /> ZONING <br />