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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />WC -Inc- C L:�e <br />Owner: Sie(J�ctni� �c�I�in__ <br />SH•ZCk11�� 5'inc,glf <br />Address: (I oa L i f It SIr (,jw <br />Phone: <br />i_,)e Sme <br />Fees (nwst accompany form): <br />Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />Subdivision w/ Survev: $200.00 + $50.00/lot <br />Buyer: M iChn r'.( aeJ <br />Address: 10_- l CarfV\V <br />Phone: <br />Original Parcel Information <br />Parcel ID #: 0-1.cc&j - 2-42 •,5 o5•c.c z- e,zwrJ Section�_Township y �, RangeIf) <br />Original Description (or attach copy): �c,r n6-ioj-� LA Z , r.o, LASL <br />Current Zoning:_Floodplair Y/ Wetlands Lake/River Class: <br />Name of Water Body: l0, �_� _ Gra, _ . Shoreland Agreement/SIPS Y& <br />Farmland Preservation Y : -3 Managed Forestry Law Yt�f: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Ky Lca C S�� <br />Acres , <br />c <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 provide(Y-N: Lake Lo <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 />Date: <br />Date: <br />Yes No <br />Yes No <br />Amount $ 7i�r� Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application:- "Approved / Denied Reason for Denial: <br />v <br />y <br />9V <br />.:.1 <br />ij <br />0 <br />I- <br />66.6-0-1 <br />6 1 <br />