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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: 7rp y)� Laren Buyer: <br />Address: a1530 Ave Address: <br />Phone: C(P5 i� '� 0a —11 Olo Phone: <br />Original Parcel Information <br />07- czo-s-qo - I(c•19-5 IS-A0o-osgoco°o <br />Parcel lD #: 07.02 -C -Z - 4o - i 6- ig-5 i 5.3(,o - 053,,,o Section L�_TownshieL4 0 Range jp <br />c7-eZo- 7..gi)-1(0-17.5 15-3(&c-05vbno <br />Original Description (or attach copy): <br />`- <br />8 \k1 Lois 3 o ? i k 9 <br />Current Zoning:_Floodplain i N: Wetlands 1l//N) Lake/River Class: <br />Name of Water Body: Ye I10,,) L<xke Shoreland Agreement/SIPS Ye. <br />Farmland Preservation YA�_-) Managed Forestry Law YA <br />New Parcel Information (� <br />Proposed New Legal Description and Parcel Size: q U4 CSM U� QXi S� I►� DC1 rc�IS <br />Acres: 1, 0_1 LD <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: L kr`4TiA,y <br />Proposed access to public waters to be provided Y/0 <br />If yes, describe access: <br />Signature of Owner: Date: <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No Ae—c— *7//� yi It <br />Does parcel require a Survey? <br />i Permit application fees submitted? ❑ <br />Yes No , <br />Amount $ � Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: Approved Denied Reason for Denial: <br />Land Use <br />/8/74/1?- Date: <br />iC <br />�0 <br />0 <br />C10 <br />0 <br />e <br />