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1=8£S (Inust APe411}patty fornl): <br />Burnett'County Subdivision Permit Application Subdivision w/o Survey $50.00 <br />01101 <br />and/or Pre -Application Form Surveyoftnri/Sor'v: 3 00.00+55 <br />�13 Subciivision�vlSurvev: X200.00+$jq,0011at <br />Owner: sl t V Ale l3,.at Buyer- <br />Address--.6267 <br />uyer: <br />Address: 6261 e -A 0hotlew <br />Phone: qS - 48 " 00903' <br />Address: (0 471 C'tolboww• tip <br />Phone: <br />07- 02a- Z -4a -1F-2.7 <br />Original Parq.1 Information <br />Pa reel Int#: 5 OS- 001 —(01M-4 pZ000p Section 2j Township 40 Range 1� <br />Original Description (or attach copy): 1" .f I'L ( tr c+ 6.'e <br />Current Zoning: t`` ( Floodploin l'N: Wetlands Y& Lake/River Class: <br />17 <br />Nature of Water Body:_Shot°eland Agreemctit/SII'S Y/N, <br />Farmland Preservation Yjl�Managed Forestry Law YO <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Nr W 9* ttr;t:t1 Lor CiAt <br />Acres: P162 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary ump requirements.) <br />Proposed access to public road: <br />Proposed access to public waters to he provide YJ ': <br />If yes, describe access: L& <br />Signature of Owner: <br />Signature of Owner - <br />Does porce:l meet 7_6 g Requirements? <br />> Does parcel require rt Survey? <br />> Permit application frees subatitted? 0 <br />Date: A�o ZG}%rS <br />Date: _ ,jd -A) -n� I <br />Yes tYo G'k' # /? <br />Yes AANo <br />Amount ,5_30e , Reed,pt#t <br />O Reconciles'with Real Property Lister Yes No Date: <br />If not, explain: <br />Land Use: <br />Reason for Denial: <br />Date: <br />