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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Owner: Buyer: <br />Address: Z'�'�v"L l c//1'i'im -. S t2b Address: <br />Phone: �� S ¢� Phone: <br />Pees (must accompany form): <br />Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00Aot <br />Subdivision w/ Survev: $200.00 + $50.00/lot <br />3 699 Original Parcel Information <br />Parcel ID #:/,�-/2S-o/ZooDSection__ 7_Township 3 Range ��-- <br />Original Description (or attach copy): PAH -" o/=- Lo 7— <br />A:f2 5 OF 5Scoi2..' 5 P e-4- 7- I <br />Current Zoning: A"-- Floodplain Y/N:___/4Wetlands Y/N: /4 Lake/River Class: N <br />Name of Water Body: 61• 4' Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: /\j Managed Forestry Law Y/N: Aj <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Gg T I �� /�6`G� l_ • s • �t <br />Acres: 7 rP ,7 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: �-T S ate{ (,c + t [. L, i.4 n,v 5 R!—A-43 <br />Proposed access to public waters to be provided Y/N: /\Z <br />If yes, describe access: 1J, /i - <br />Signature of Owner:./E/y>� ��%1(� ��G�/L►y Date: Z64-LIe/� <br />Signature of Owner: <br />Date: <br />Y Does parcel meet Zoning Requirements? Yes No <br />i� Doesparcel require a Survey.' Yes No <br />O� <br />A Permit application fees submitted? ❑ Amount $ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: Approz•ed / Denied Reason for <br />]� i JI t <br />Land Use: <br />— /VD s,0lt'Vs /p& -,1 14 -Z Zc,H I'M <br />Date: ' <br />d <br />m <br />W <br />0 <br />00 <br />W, <br />