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Fees(must accompany fora:). <br /> Burnett County S'47bdivISAO".fl Permit Application SOdiMsien �/.Survey: 55000 <br /> 7+➢➢t1/OY Pre—Application PD➢'➢lfl - Sur:zy.fExisting Parcel S50.00/lot <br /> re $gyp Cfamdi,ts�ioaw+/Snr�r,: azoo.00+S5a0on.r <br /> PFDy� � L- Umyw <br /> Address: _ ZD� f�l � flQi /iCd - Addres ip6.7'/ri '3J - ✓e-yr"�`�",JC'y . OZ-D00— <br /> r�i-u�u� 1 `�'!(i �/8�D � I a•J-o 3�"a"yi rY-3o -� 03 ocn=olio c <br /> Phone: � 10 - 2'CA- 3`110 Pho,e:�G�d38'?"yi/Y 3e 3 QY b�arrm <br /> Original Paiccl In form afnn <br /> Pn reel SD R: Ol`L'OC-QAr060 Section 36 Township //N Range t ✓ly <br /> Original Description (or attach copy): AUC S pv r A/W 5E . 6E S (,'V --5105C <br /> F4'd!�z tC ce X07`5 i :- 3 D V/AK�P2 til LLfl6 <br /> PUO <br /> Qp o <br /> Current Z.nm YUl - h�:�5 FloodplairO'N: //JJ Wetlanndq&:: {, <br /> Lake/River Classification: Name of Water Bodv: <br /> Shot eland Agreemt orSIPS <br /> 1,:1 Farmland Preservation Y/6NIanaged Forestry Law /N• `� <br /> Netr Parcel Information _ <br /> Proposed New Legal Description and Parcel Size: _ 77 <br /> Acres: - 133- Y 1U <br /> (If pa reel is to be surveyed,providepreliminary map. See attached for preliminary map <br /> � requirements,) <br /> Proposed access to public road: 1&1 elezlil / /J/Q �lPl'I A(C (i/A ,e i7 4e J C & <br /> �k / 2 2 2d <br /> Proposed access to public eaters to be provided YIN: "• <br /> Yf .d <br /> ecri"' <br /> decribe access: <br /> N _ri�natnreofOwner: _ Date: Z'(-$'•d <br /> 5 <br /> Signature of Owner li uSlr' : t - f] <br /> ar, <br /> Date: o <br /> ➢ Does parcel n7ce, <br /> Zoning Requirements? Yes Na _ <br /> r ➢ Does panel require a Survey? - Iles. No <br /> c <br /> - ,I <br /> o D Permit apylicalionfees suburi(!ed? - '❑ Amount Receipt° <br /> 'o <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: - - n--a <br /> Application: Approved / Denied Rensonfor Denial: <br /> BU� C7 JNTY Lj <br /> Land Use: Date: <br />