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Fees (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/ Survey: 5200.00+$50.00/lot <br />Owner: &6_f4- '%" tfajBuyer: <br />Address: i 5o5C� �O1 t"` Address: <br />I✓tN 5 �. <br />Phone: 1 a��- aQa Phone: <br />Original Parcel Information <br />Parcel m #: 07- Olga -39- 16 - 014 - 5 n5 ee2-o24r4ection0 <br />_Township �9 Range 11r� <br />Original Description (or attach copy): _ ?c- L G <br />0\i Lr',i Z Lo� , j q Sub -lrc3 <br />esm3r yY'$ /QIP, <br />Current Zoning: 12R\ Fl,,dpi,i YWetlands <br />Lake/River Class: ` <br />Name of Nater Body:�E? V `15 1�� <br />Shoreland Agreement/SIPS Y/v: <br />Farmland Preservation <br />lanaged Forestry Law Y <br />New Parcel Information`` <br />Proposed New Legal Description and Parcel Size: <br />�� <br />tXu 1 Lo, CSM <br />Acres: 6.5q <br />(If parcel is to be surveyed, provide preliminary map. <br />See attached for preliminary map requirements.) <br />Proposed access to public road: e-1{ % t <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />Signature of Owner: Robert W. Herzfeld <br />Date: 02:58 PM CDT <br />Donna M. Herzfeld <br />07/22/2018 <br />PM CDT 18 <br />'"-' P <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No AG,- 712-6112- <br />> <br />12-61/g> Does parcel require a Survey? Yes No Z Z <br />rn <br />O� <br />i Permit application fees submitted? ❑ Amount S®' Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application Approve / -Denied Reason for Denial: <br />