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0 <br />Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Owner: GAK.19rjA.J a L MAAJG61,SG1JBuyer: <br />Address: is 919 5TAm RO42 .7-0 Address: <br />IFIF210—Mm <br />Phone: 411 -ei64- 0&58 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 />O'+ -OW -2-4Q X4.34.'301 -000-01200C <br />S> ID #: 04-018--39-110-3�F: O-0190-0/300OSection_? Township 39 Range 1(p <br />Original Description (or attach copy): Lorli 1 Arta Z of GSM VII., P25' No. 1935 <br />Current Zoning: IZRI Floodplain Y/N: Ll Wetlands YIN: N Lake/River Class: <br />Name of Water Body: N4 Shoreland Agreement/SIPS Y/N: N <br />Farmland Preservation Y/N: kJ Managed Forestry Law Y/N: t j <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: CoMBtwlr_ L.tr i 14^217 2- Is,Yio Lei' 1 <br />Acres: 10.33 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: tr.rAM W44�,j4`1 qLo <br />Proposed access to public waters to be provided Y/N: 1\I <br />If yes, describe access: <br />Signature of <br />Signature of Owner: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />Date: �I I <br />Date: <br />➢ Does parcel require a Survey? Yes No <br />➢ Permit application fees submitted? ❑ Amount $ 0/ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, <br />Applicatio : Approved /-'Denied Reason for Denial: <br />Land Use: <br />Date: <br />