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Fees (must accompany fonn): <br />Burnett County Subdivision Permit Application Subdivisionw/o Survey: $50.00 <br />Survey of Existing Parcel: $50.o0/lot <br />and/or Pre -Application Form Subdivision w/ Survev: $200.00+$50.00/lot <br />Owner:L. , J. e <br />Address: 5 7 /V `ic:T ���� _ Address <br />Z <br />'D eve_ IL %�ken" <br />3/5 <br />IZ,�st el*w , _'L _504 <br />Phone: Seo 7 l - 3,?.0 Phone: (,:�W— 570— 3 5 J/3 <br />Original Parcel Information <br />G -i- GG(,- �- 3�-f?-L(a-s GS•GCtri%-Gl(vGCU f p <br />Parcel ID#: G7C01.--;�.__I7-1b5 c5 CGb C11f.Socr+ Section IC Township 39 Rangel? <br />Original Description (or attach copy): t0 q C S�4j t $Or <br />Current Zoning: R�� Floodplain Y,�: Wetlands Y/0—Lake/River Class: <br />Name of Water Body: <br />Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Ylk) Managed Forestry Law <br />New Parcel Information ll r <br />Proposed New Legal Description and Parcel Size: A/c w CC'. k r rd .Svc c, iyM4,4 (CS/h <br />Acres: <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 />Signature of Owner: <br />> Does parcel meet Zoning Requirements? <br />> Does parcel require a Survey? <br />> Permit application fees submitted? ❑ <br />Date: /1yZ12 <br />Date: 9_1q_1 <br />Yes No <br />Yes No <br />O <br />Amount $ ZS�0 ' Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: Approved / enied Reason for Denial: <br />Land Us <br />Date: <br />