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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Fees (must accompanv 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 />Owner: 7o�\n + M,c-yieA - Mork c1 jn�,} Buyer: CAle lib , <br />Address: a9Q9 \,J f-le-er— Lc,ke- 1?.cA Address: <br />Snbu n-4 J I 54 $ 3O <br />Phone: o l s) 911- oua y Phone: <br />Original Parcel Information <br />01 -CIA -a•41 -IS --12 S ©J. c3cS cj3Gc)C <br />Parcel ID #: 6S- cc'3-ejxyMection_L2_1_Townshie Ll I Range r <br />Original Description (or attach copy): Los 9 a�- C,SMy as 9 ray G <br />Current Zoning:P\R�) Floodplain&N: Wetlands YO—Lake/River Class: <br />Name of Water Body: D g,�t_r' Lc,,V Q— Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y Managed Forestry Law Y <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: N, iv ke✓%sr-( Z Cw f C_J,161 <br />Acres: -10 , Lol <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: eKi ! f� T <br />Proposed access to public waters to be provided Y/N: IL.4 <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 <br />➢ Does parcel require a Survey? Yes No <br />� Permit application fees submitted? ❑ <br />❑ Reconciles with Real Property Lister Yes <br />If not, explain: <br />Land <br />m�- <br />Amount $ �OO <br />Reason for Denial: <br />No Date: <br />Date: <br />Receipt # <br />