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Fc�s (must accompany form): <br />Burnett County Subdivision Permit Application Sulxlivisiunwh)Survev: $50.00 <br />Sunny or Existing Parcel: $50.00Aut <br />and/or Pre -Application Form Subdivision w/ Sunev: $200.00 .F $50.00/lot <br />Owner: o(. -.g A4bAg rL-- Buyer. <br />Address Cj0 ¢¢ /C6t�AnlDr,/2_ P—'h Address: <br />Phone: -ll� /oi6 Phone: <br />Original Parcel Information <br />Parcel I D #: Z S z S� Section Z Z Township 36 Range <br />Original Description (or attach copy): EA--, <br />Current Zoning:A-1-- Floodplain Y/N: Wetlands Y/N: N Lake/River Class: N <br />Name of Water Body: �/4 Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: /� Managed Forestry Law Y/N: Al <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: eT 1 OF W6 6✓ CS A, <br />Acres: Z , / 8 <br />(if parcel is to be surveyed, provide preliminary map. Sec attached for preliminary map requirements.) <br />Proposed access to public road: �jl,o,�y-I-� 0 <br />Proposed access to public waters to be provided Y/N: /Lt <br />If yes, describe access: <br />Signature of Owner: ik�Z + 1 Dates <br />Signature of Owner: <br />Y Does parcel meet Zoning ReguiremenlsY <br />Does parcel require o Survev' <br />Y Permit application fees submitted_" ❑ <br />Date: <br />}'es No <br />m O <br />Amount S 2 <br />❑ Reconciles with Real Property Lister Yes No <br />If not, explain: <br />Date: <br />Receipt l/ <br />