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Owner: Buyer: <br />Address: �i COtX1 Q ci �. &Y-185 Address: <br />Phone: <br />Phone: <br />VV o r) I.e, <br />Original Parcel Information <br />IS -508 - C) <br />Parcel ID #: 01- 032.. 2 - 4- 1 - K zz - 5 Section-I.E-Township 41 Range( A <br />Original Description (or attach copy): Lo4-6 3-� G)OGJL to.f ��'G¢ S �,Ysj, A ldc ,,an <br />Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Ly L I. L on \. � 4,' <br />Acres: , (p <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: �Jlye S <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 />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? Yes No <br />Permit application fees submitted? ❑ Amount $ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicat' Approved enied Reason for Denial: <br />Land Use: - Date: 2 z3 ZO <br />O <br />5 <br />VAN <br />Z <br />b <br />z <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application <br />Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />and/or Pre -Application Form or Map Review Form <br />Subdivision w/ Survev: S200.00 + S50.00/lot <br />Owner: Buyer: <br />Address: �i COtX1 Q ci �. &Y-185 Address: <br />Phone: <br />Phone: <br />VV o r) I.e, <br />Original Parcel Information <br />IS -508 - C) <br />Parcel ID #: 01- 032.. 2 - 4- 1 - K zz - 5 Section-I.E-Township 41 Range( A <br />Original Description (or attach copy): Lo4-6 3-� G)OGJL to.f ��'G¢ S �,Ysj, A ldc ,,an <br />Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Ly L I. L on \. � 4,' <br />Acres: , (p <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: �Jlye S <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 />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? Yes No <br />Permit application fees submitted? ❑ Amount $ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicat' Approved enied Reason for Denial: <br />Land Use: - Date: 2 z3 ZO <br />O <br />5 <br />VAN <br />Z <br />b <br />z <br />