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Fees (nmst 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 ,v/ Survev: $200.00+$50.00/lot <br />Owner: Buyer: <br />Address: 01530 31o,tne. AV e. Address: <br />Phone: (CPS i)• y Ua -11 OLP Phone: <br />c')- etc -2- �J- 110 19 5 , Oripinal Parcel Information <br />-3teL - b 47c00 <br />07- o20-2--4o-1(c-19-5 15 - -Lc -o5y000 <br />Parcel ID#: 07 -02c -2 -4o -t6-14-5 IS i(no-oS3poo Section <br />—ft_Township 4O Range 1p <br />c7- r5-3to0•u5cj a - <br />Original Description (or attach copy): <br />Tenszn's Lakest-xore- b,y c P Vel s Lake. Lai-,, 0 icY , W <br />3 +y o� 131k'R <br />Current Zoning:_Floodplain i N: Wetlands 11//N) Lake/River Class: <br />Name of Nater Body: Ye It7 L'� La 'e Shoreland Agreement/SIPS Y& <br />Farmland Preservation Y� Nlanaged Forestry Law YA ) <br />New Parcel Information (� <br />Proposed New Legal Description and Parcel Size: q UA CSS�,{ ' 1yt e Da r,. t� <br />Acres: I. a(D <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road:�4 /104, <br />Proposed access to public waters to be provided Y/o <br />If yes, describe access: <br />Signature of Owner: <br />Signature of Owner: <br />Date: <br />Date: <br />> Does parcel meet Zoning Requirements? Yes No Ae—c- 3101P �;.f <br />> Does parcel require a Survey? <br />> 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 />� , �� Date: <br />d <br />R <br />�0 <br />SZi <br />