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4 - <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />and/or Pre -Application Form Subdivision w/ Survev: 5200.00+$50.00/lot <br />Owner: m i c hex r l f.�� o.J Buyer: .9 <br />Ma, Ii -A �- <br />Address: Cl/ 90 JC-th\acC-t . ,(i Address: <br />z <br />n k e rima, n .sa v�2 <br />Phone: b 5'/ 79q - '?q --)I Phone: <br />T <br />Orieinal Parcel Information <br />Pa reel ID#:V7—x)30 o?3*_A(6-C6'-3 ��-cc�5=�1� Section :3' Township 3 Range _ <br />O <br />Original <br />Description (or attach copy): 66M 1)'Z <br />19 4,) f.' <br />`�ki <br />Current Zoning: _ Floodplain 1' N: Wetlands Y : /LaWlkiver Class: <br />Name of Water Body: CU00 k A i-c9-k� N® Shoreland Agreement/SIPS Y(N� <br />Farmland Preservation Y62-1—Managed Forestry Law 1(%N:� <br />New Parcel Information <br />1 <br />Proposed New Legal Description and Parcel Size: <br />+ Ccs <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 />m <br />Proposed access to public waters to be provided Y/N: <br />l <br />If yes, describe access: <br />__Z <br />Signature of Owner: - >� Date: <br />Signature of Owner: Date: <br />e <br />B <br />> Does parcel meet Zoning Requirements? Yes No <br />a <br />e <br />> Does parcel require a Survey? Yes No <br />19 <br />�t <br />r Permit application fees submitted? Amount S. Receipt f# <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Land User <br />6G J, jJd <br />