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f3.73� <br />Fees (must accompany fonn): <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+$50.00/lot <br />N L N c 6 s+ I-'- C_ <br />Owner: f1 ocri S Nt'�:S Buyer: b <br />A <br />Address: �5 > of 1 3$V- • Address: 3 <br />A <br />Phone: `I/.5- � �1a/ - �I•SD Phone: <br />Orit=.inal Parcel Information <br />ParcelSection `% Township Range 1,5- <br />Original <br />SOriginal Description (or attach copy): 6-o ej , .D `i 3 0 <br />n <br />CD <br />9� <br />.o Current Zoning: Floodplain Y N Wetlands YAD Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y6 i <br />0 <br />.. Farmland Preservation V6. Managed Forestry Law YA <br />New Parcel Information �+(� <br />Proposed New Legal Description and Parcel Size: <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: p <br />d <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />j 1�_� Signature of Owner: Date: b ' 3y— l <br />Signature of Owner: Date: 3 <br />Does parcel meet Zoning Requirements? Yes No A <br />�t <br />➢ Does parcel require a Survey? Yes No <br />Permit application fees submilled? Amount $_ qO(), GQ _ Receipt k <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Ap <br />Land Use: <br />Approved�Denied Reason for Denia <br />Date: BURNP11 f`i'll IAITy <br />ZONING <br />