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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Owner: (" ! a r V Ta s � a. O Buyer: <br />Address: ! 19 V6 -T-- Sri AfVe- N Address: <br />t r .1�1r� s'5082 <br />Phone: �l Z b g `- t0� % 8 Phone: <br />Fees (must 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 />Original Parcel Information <br />-s 05' -oat -01/000 <br />Parcel ID /5--24-03- OS -002 Qti nS <br />/ Ab Township 3 8 Range J <br />Original Description (or attach copy): I�T0 <br />y V 1� �0 e <br />C--5)6V'f /of 2. <br />Current Zoning: �„ Floodplain Y/N:_�—Wetlands YIN:_y Lake/River Class: <br />c �pp� <br />Name of Water Body: Sp vi 4 Shoreland Agreement/SIPS YIN: O <br />0 <br />Farmland Preservation Y/N: d Managed Forestry Law YIN: <br />—2-0 <br />New Parcel Information / <br />Proposed New Legal Description and Parcel Size: <br />Acres: 1 • / O <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 YIN: ye S <br />If yes, describe access: Lit re e <br />Signature of Owner: T !(L� / L.. - Date: 1 t <br />'„f' <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No CkO- ,,pp2070 <br />➢ Does parcel require a Survey? Yes No r`«' 7/ % sI ,9� <br />)�' Permit application fees submitted? ❑ Amount $ 2-5V, B� <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Land U <br />I -1-benied Reason for De <br />4k �G 2 4 & <br />Date: <br />Receipt # <br />C <br />