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Fccs (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: $200.00 + $50.00/lot <br />L <br />Atot � C eY 1 <br />Owner: Buyer: <br />Address: ) ) `i u CCYI i n bA R Old D Address: <br />Gran t -s. tAg(a , w) 548g0 <br />Phone: [ 5 `7 �� - 1� g g Phone: <br />Original Parcel Information Q <br />Parcel ID #: 0 7- L)qZ - 2-38 -) P - 03-j Section Q -S Township 38 Range /8 <br />Original Description (or attach copy): 0 Y}©00 _vI/©pp <br />See n-++nr,-iH 5y, A <br />Current Zoning:4-2"- Floodplain Y/N:_�__Wetlands Y/N:_Lake/River Class <br />Name of Water Body: 9,18 Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: <br />Managed Forestry Law Y/N: N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: <br />5 cc (ate ;cL dx <br />Acres: -12 acres <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Cn[Anj3A D <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: ( ) _21 - „ J"'n /I - <br />Signature of Owner:,. j_�, 5 Xl YUV\ 6� )L�eZ\ J4. Q2_ <br />Signature of Owner: U „h i" A K '---5T. 1 ►l I S Y, k r- a Da&---,, q-22- <br />➢ Does parcel meet Zoning Requirements? <br />➢ Does parcel require a Survey? <br />� Permit application fees submitted? ❑ <br />Yes <br />Yes <br />Amount $ <br />No Gf/?i7 /O <br />No O <br />Receipt # <br />Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />za3zz <br />Applicat.9R Approved / Denied Reason for Denial: <br />Land Use: <br />2-al�" Date: <br />m <br />;4 <br />v <br />0 <br />�o <br />