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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/ Survev: 5200.00 + $50.00/lot <br />Owner: l Gt ►r V Ol Buyer: <br />Address l 19 V6 T" A IkA tV Address: <br />'K(jdc',-% . M1\j 5,5(9-67- <br />Phone: <br />5082Phone: 6 J% -2-6 8— 60 0 8 Phone: <br />Original Parcel Information <br />07_01y -z -3? -1r -Z6-9 OS' -001-011600 n / <br />Parcel ID #: O 7- p/t,<- Z- 3g - /s' -2L�//s OS -0602 - n � QQeon/ A b Township 3 9 Range 1 / <br />57 <br />Original Description (or attach copy): CTy V 17' /0 ( A rl d eA /� B <br />d,r j0 t 2 . <br />Current Zoning: �k I- Floodplain Y/N:_�_Wetlands YIN:y_Lake/River <br />Name of Water Body: S La/l a Shoreland Agreement/SIPS Y/N <br />Farmland Preservation Y/N: f� Managed Forestry Law YIN: J�d <br />New Parcel Information <br />„( / <br />Proposed New Legal Description and Parcel Size: G A �E' <br />Acres: /.79 <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 />Signature of Owner: <br />l n Fe- e <br />Date: <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No # 2-070 <br />➢ Does parcel require a Survey"? Yes No R« 7/ % s1JG <br />00 <br />➢ Permit application fees submitted? ❑ Amount $ 2,V, Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Land <br />I L-benied Reason for Denial: <br />►KG>G24h--,q <br />Date: <br />