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Fees (must accompany form): <br />Burnett County Subdivision Permit Application SubdivisioawtoSurvey: $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 />Owner: I<C V j'V To hh.Pvn Buyer J OS 4 V'q 4- L OR I &<'j 2.64 <br />Address: "5714 ( M Co 40 tJJZ?' N k-' Address: __H 80 q L, E04a/1 .S11. M6 <br />JZAASEy M_,- SS3,3 9L4t'M4F. �. SS44Q <br />Phone: Phone: 612 -*44 - 123Q <br />TCck /P 2.CgS t Orissinal Parcel Information <br />ParcelSppOS�DOS Dinit�"jSection�Township 41 Range <br />T <br />Original Description (or attach copy): !�rhago A- I !A, 2 B,e�Lenu + <br />Current Zoning:!Floodplain Yo 'wetlands Y6N Lake/River Class: <br />Name of Water Body: <br />Shoreland Agreement/SIPS f/N: '— <br />Farmland Preservation YIN: -~` Managed Forestry Law Y&t <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Aie k, ! L,.f C �'A7 <br />Acres 1 r 0 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: y/'rs <br />Proposed access to public waters to be provided 1V <br />If yes, describe access: <br />Signature of Owner: <br />Signature of Owner: <br />➢ Does parcel meet Zoning Requirements? <br />➢ Does parcel require a Survey? <br />> Permit application fees submitted? ❑ <br />Yes <br />Yes <br />Amount $ <br />Date: 7� �( <br />Date: <br />NQ /,eS'3(o A2,,G 7/11/& <br />No <br />Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />D <br />0 <br />VP <br />A- <br />r <br />0 <br />