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Fees (must accompany form); <br />Burnett'County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />and/or Pre -A lication Form Survey ofExistin Poral: $50.00Aui -/910pP Subdivision w/ Survev; 5200,00+ 550.00/lot <br />1` C�whet' <br />Owner: 13 �1M"" Puc%v�21 II w (f0me(-on 9:1!2b e s <br />Address: _�flcil S. sc)6sov\ %a���d Address: 17�5 % � tf"3a5 R,� <br />(,Ue.�s <br />Phone: r11,�'�(r�6 --Yy Phone: 71.5_•566-1695 <br />r�7-ol�-a-39-i6-ao-1 bi-oc�,-er�cr�o <br />o!-accr o ooc O, rieinal Parcel Information <br />�1 <br />a-pc�o-r�ij3oc�n <br />Parcel ID#: C��' Section a0 Township 37 Range /G <br />Origlnal Description (or attach copy): l 4s I+:? C51K UIo <br />4.1,41 csm ua.s P6-1<dW wg)'4--tkA Pry tJe7,dF <br />�irF tine aC. in sal,/sa Ex ld'7/3/3-cl£f�/sd� flwY <i- Pri <br />ct <br />N 6 w E 41,r Z� of G -a f Tr I tr W o9 R a FN <br />1Za3 fY 3 <br />PC <br />Current Zoning: Flood lal, <br />p `� WetlandY N: Lakc/River Class: <br />o <br />Name of Water Body: 6 VA- R Luer Shoreland Agreementt//SIPS Y <br />\ <br />R <br />Farmland Preservation Ytn 1. Managed Forestry Law N- <br />,/ <br />New Parcel Information V•� - (qb P, 00—M —f <br />(1 <br />1-2" <br />Proposed New Legal Description and Parcel Size: eU-) L �1 <br />::5 <br />� <br />— Acres: ? <br />(If parcel is to be surveyed, provide preliminary neap. See attached for preliminary map requirements.) <br />Proposed access to public road: <br />Proposed access to public waters to be provided Ys <br />m <br />:? <br />If yes, describe access: <br />Signature of Owner: Date: <br />Signature or owner: Date:Al-4—,1`7 <br />c <br />a <br />D Does parcel meel Zoning Requirements? Yes JVo <br />n <br />Does parcel require a Surve <br />p 9 Y? Yes No <br />5' <br />Permit applicallon fees submitted? Amount $ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />Q <br />a <br />If not, explain: <br />n <br />o <br />M <br />a <br />N <br />Applicatio Approved / enied Reason for Denial;_ <br />- <br />Land Use• 7 Date: <br />