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09/14!2017 08:35 6514839902 THE UPS STORE P"GE 02!02 <br />Fees (must accompnay (otml: <br />Burnett County Subdivision Permit Application Subdivision w/o Survey. 550,00 <br />Survty of Existing Pend; SS AIIO <br />and/or Pre -Application Form Subdivlsionw/Survev: 3200.00+150.00/l0 <br />Owner: V l"P * Buyer: <br />Address: Address: z <br />D <br />Phorte: Phont: <br />l -Y azf D�,-o Original Parcel Inftarma{Qe <br />�S-4 k6—©a�600 is Yk�—o xY000 <br />PitrcelIDtl:TownshlP 141 Range_jq <br />Original Description (or attach copy): V1�> e� r►�.c� '^ ^ 1 'r <br />z <br />Current Zonin¢: Floe dplalr�l_ wetlands Y(i� alC liver Ctrs,: <br />Name of Water Body: Sbordand AgreemenUSfPS V6�_ _ <br />F'armignd Preservmlon Y del, Mastsbed Forestry Law <br />Ne rgrW Inform,a/tjoa <br />Proposed Nzw Legal Description and Parcel Size: _� JPS l of 5 w, <br />- <br />Acres:— (9 <br />(If parcel Is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: aac�S4t c, <br />=r <br />Proposed access to public waters to be provided WN: <br />�Ifyes, describe access: <br />� r <br />Signature of owner:- y <br />V Date: <br />Sign9ture or Owner: <br />Date: <br />n <br />6 <br />➢ Doesparcel meet zoning Requirements? <br />Yes No <br />D Does parcel require a Survey? <br />Yes No <br />5' <br />Q0 <br />i Permit applicallon fees submllred? O <br />Aniounl S Receipt N <br />❑ Reconciles with Real Property Lister <br />Yes No Data: <br />e <br />az <br />x <br />0 <br />If not, explain: <br />Application. pproved / D led Reason for Denial: _ <br />Land Use: <br />