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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form or Map Review Form <br />Owner:L4� L $uye�': <br />Address: <zAddress: <br />Phone:���"� <br />Original Parcel Information <br />Fees (must accompany form): <br />Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />Subdivision w/ Survev: 5200.00 + $50.00/lot <br />&;4 64,4) <br />-35z;' y <br />Parcel ID #�: /(�% �,�L', ��— y2jiJ -� Section/ 3/ Tow1nship �d Rangeolf- <br />Original Dc'scri�ioii' or�ach co L%G� Lt e'l�! L <br />g P ( copy): 1' 7 <br />Current Zoning:Floodplain Y/N:—&L---Wetlands YIN:�Lake/River Class: <br />Name of Water Body: VG11e 4Q /L lkoel'� Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Al Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Sizer <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />/I <br />Lc4 <br />Signature of Owner: Date: <br />Signature of Owner Date: 47%Z'r—�/ <br />➢ Does parcel meet Zoning Requirements? <br />➢ Does parcel require a Survey? <br />)�' Permit application fees submitted? <br />❑ Reconciles with Real Property Lister Yes <br />If not, explain: <br />Land Use: <br />Approved / <br />Yes No <br />Yes / No <br />Amount$ p-C-br,Cc) Receipt# <br />No Date: <br />Reason for Denial: E—HURNETT • INTY <br />Date: ZONING <br />C <br />v <br />d <br />