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Fces (must accompany torm): <br />Burnett County Subdivision Permit Application Subdivisionw/o Survey 550.00 <br />and/or Pre -A lication Form StuvvyofExisting Parcel: $50.00t1ot� <br />PP Subdivision w/ Survev: 5200.00 + 550.00,1ut <br />Owner: �orn 6.Jerptue5 Buyer: <br />II ro <br />Address: 75-R3 ft)rtt n Address: <br />o <br />Phone: '7l� ' tc 5 (v �� <br />Phone: <br />(s-oo�I- D37oco Original Parcel Information <br />001/- 63Scx� <br />Parcel ID #: 15 o0q- 0_3L?anz' <br />Section vZ Township I-// Range /(o <br />Original Description (or attach copy): C) incz� <br />lowNsde, "i tb. c"I'.i, <br />LL L (o I oc k, 3 <br />Current Zoning: Floodplain NWetlands <br />Y*: Lake/River Class: <br />Name of Water Body: <br />Shoreland Agreement/SIPS V0!_;.L <br />Farmland Preservation )0: <br />Managed Forestry Law 17N� <br />New Parcel <br />Information <br />Proposed New Legal Description and Parcel Size: ztoewu c2 to 4 c S 1M <br />Acres: 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 VAN: <br />If yes, describe access: <br />Signature of Owner.;' <br />Date: <br />Signature of Owner: <br />Date: <br />> Does parcel meet Zoning Requirements? Yes <br />No <br />> Does parcel require a Survey? Yes <br />No <br />� <br />Permit application fees submitted? ❑ Antolini S le9e, Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: Approved / Denied Reason for Denial: <br />Land Use: Date: <br />