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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision who Survey: $50.00 <br />Survey of Existing Parcel: S50.00/lot <br />and/or Pre -Application Form Subdivision w/ Survev: 5200.00 + S50.00/lot <br />Owner: :TI 7Mt A&)41L%. Buyer: rp <br />Address: Slat' M4aZAJW-#,i OV -46 _NL Address: <br />Z <br />ct L <br />Phone: �' 4"i 7� Z` C 4 Phone: <br />Original Parcel Information <br />Parcel ID #: cry -CV 1- Cit, t -V 1 Section Township ir-1 Range 14 - <br />Original Description (or attach copy): 5&S lam? a4t� tD + <br />-e <br />Current Zoning: RIZ I Floodplain Y/N:.. y_Wetlands YIN: N Lake/River Class: <br />Name of Water Body: PCCA U41C Shoreland Agreement/SIPS Y/N: 1-4 <br />Farmland Preservation Y/N: I4 Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: 2&,,3 MAP V_Ia2 x <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />Signature of Owner: <br />'-L ,_ C L z 1< C 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? ❑ Xt A-- Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: <br />Land Use: <br />Reason for Denial: <br />Date: <br />