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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: $200.00+$50.00/lot <br />Owner: �06T(X i" b aP' 'T,lA <se � Buyer: <br />Address: �1aS W I� � �"�(J" Address: <br />tA)1'WsTp�' mow/ S y8�3 <br />Phone: 7( J 7_73 Phone: <br />Original Parcel Information <br />Parcel ID - L'� d ' 5--Z14 — S Section Z y Township �() Range / S <br />o' -00(o-3) LtOUO <br />Original Description (or attach copy): <br />61 6 4- a/= fi(a l Y 63 -)(Cr'? T_ w S yc„7 <br />Current Zoning: i2� Floodplain Y/N: Al Wetlands YIN: _�Lake/River Class: N <br />Name of Water Body: N 1A Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: 1-07—/ Lo T" Z CSM . <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: (T k1 S (7N 6— <br />Proposed access to public waters to be provided Y/N: 6! 4 <br />If yes, describe access: <br />Signature of Owner: Date: Ja h 9 3 de�VZS <br />Signature of Owner: <br />Date: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? <br />Permit application fees submitted? ❑ <br />Yes No <br />Oe <br />Amount $. 3 Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Isind ITew <br />/ enie eason for Denial: <br />Dote. <br />C41 7s <br />d <br />m <br />Z <br />itl <br />W, <br />