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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 + $50.00/1ot <br />Owner: /, P F, ! iKr\ n F Buyer: <br />Address: n 14 Address: <br />Phone: 7 4 ?, S' 5 D Phone: <br />Original Parcel Information <br />Parcel ID #: p-1 ,n g- _y6 -/y_2; _E a.; ccs 3 e,,YoceiSection-23—Tollwnship n/o 41 Range <br />Original Description (or attach copy): K, n Vd t 2 lex <br />1,-,S/17 V'f� A Q , r /e) <br />Current Zoning: A. Floodplain Y/N: A/ Wetlands Y/N: �� Lake/River Class: <br />Name of Water Body: VI,g- Shoreland Agreement/SIPS YIN: 14/ <br />Farmland Preservation Y/N: /V Managed Forestry Law Y/N: /l/ <br />New Parcel Information II <br />Proposed New Legal Description and Parcel Size: % c J o <br />3 V e) /L, <br />Acres 3 y �' <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: q/ <br />If yes, describe access: <br />Signature of Owner: ' d X-, 01.e e - Date: _ " A oS " 1 13 <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No k e, 3/ZZ1Rj1 <br />N <br />_ ➢ Doesparcel require a Survey? Yes No <br />D <br />°Q Permit application fees submitted? ❑ Amount $ Z ` Receipt # <br />r. ❑ Reconciles with Real Property Lister Yes No Date: <br />0 <br />If not, explain: <br />0 <br />a <br />y <br />Application. A roved / enied Reason for Denial: <br />cM 5 I�y op 14 C�it/l <br />Land Use: Date: <br />