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�M <br />Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Fees (must accompam, Como <br />Subdivision w/o Survey S5000 <br />Survey of Existing Parcel 550.00/ 01 <br />Subdivision w/ Survey. 1200 00 + S50 001loi <br />Owner: --L�' <br />C, i rr'�c <br />��1 ,—� <br />( �' <br />Buyer: <br />, <br />�� <br />Address: <br />-i f E� �ea.�� ncr I <br />� "� <br />e ( feet ' q�o►ddress: <br />lI) 1)b LA f./ f L,_) y <br />Orieinal Parcel Information <br />ofi-alb-�7-yU-t�-/d-3 �3-G�>y-_c:tgcxk� <br />Parcel I D#: , s -e > > - u , �. cr,.� <br />�- 4• > r - xcnrr;,, SectionI �_Township YU Range /j <br />,­iginal Description (or attach copy).--I�AL12 U p � q e C Ut , I � e' <br />4045 /0,-/l + Q, <br />Current Zoning:R _Floodplain(Y/N: Wetlands YLNj__/Lal�te/River Class: <br />Name of Water Body: _cam., Imo.':c� t -C K e Shoreland Agreement/SIPS Yr1N: ; <br />Farmland Preservation Y/6 Managed Forestry Law Y :a <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: 2,-J <br />Acres: ` S8 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: ,/ C <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: <br />i Does parcel meet Zoning Requirements? Yes No <br />i Doesparcel require a Survey? Yes <br />No <br />5' <br />Qo i Permit application fees submitted? f Amount S Receipt it <br />W ❑ Reconciles with Real Property Lister / \Yes No Date: <br />0 <br />a If not, explain: <br />R <br />0 <br />Q <br />u <br />Applicatio �roveDenied Reason for Denial: -111 2016 <br />Land Use•4Zi Date: Z01 1111413 <br />W <br />