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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form j <br />GSI A Stuk1 <br />Owner: �4Pn0I5 5 a�54RG Buyer: <br />Address: 5-J.7 �r 6535 © (A A Address: <br />L01 S' -jy-l- + (hJ-T <br />Phone: �_- 5l - aa(o —//0 1 Phone: <br />Orieinal Parcel Information <br />Fees (must accompanv fonn): <br />Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />Subdivision w/ Survev: S200.00 + S50.00/lot <br />c <br />Parcel ID #: 07-o I S' -,7-31 /(o' c�;?- �2 0:3 _Cccl_o Section-2--TownshiQ,3"t Range <br />Original Description (or attach copy): X &(o t o � s 1 U) <br />Current Zoning: 12 1 <br />_Floodplain Y,(y,:' Wetlandsol , Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y�IY; <br />Farmland Preservation Y/Ni:;- Managed Forestry Law Y�N:,- <br />New Parcel Information V. <br />Proposed New Legal Description and Parcel Size: n L} - <br />Acres: 7 ; U u t/ <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 />X Signature of Owner: Date: <br />X Signature of Owner:. _ Date: 5 '� <br />Does parcel meet Zoning Requirements? Yes No <br />io Does parcel require a Suivey? <br />r Permit application fees submitted? <br />❑ Reconciles with Real Property Lister <br />If not, explain: <br />Yes No <br />dam_ <br />Amount $ Z -5w. Receipt 9 <br />Yes No Date: <br />Application Approved / Denied Reason for Denial: <br />Land Use: <br />on 1 I /S Z c <br />IV <br />A <br />C <br />73/ u/ `—' <br />Date:_ Z'QFliiur� <br />