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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdr*ionvrloSurvcy s5000 <br />and/or Pre -Application Form SuMvisi ExilSurvarcel: 550.{iQ/Mt <br />Su(�ivisiamw/surnv MOM +sso.00na <br />Owner: _ ]. 1. l lq_ CSc h rv,' , -z Buyer: <br />Address: 2 S -A Lp Cbu njV pick Address: <br />5�Ak _Lo e. . VAS. 54 ri i <br />Orizinal Parcel Information <br />Parcel ID #: a5. ccs) - otzow Section—ak`"fownship q0 RanPe_L2_ <br />Original Description (or attach copy): PCL volt t- I__n� I <br />Current Zoning: Floodplai& �Yetlands YIN: Lake/River Class: <br />Name of Water Body: L, }kQ yelkuaAA Lake— P, Shoreland Agreement/SIPS Y/N: �— <br />Farmland Preservation Y Nlanaged Forestry Law Y'r: <br />Ne`v Parcel Information <br />Proposed New Legal Description and Parcel Size: M e.� J Loo C—SM <br />Acres: -9. % - <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: ¢ 5 p <br />n <br />Proposed access to public waters to be provide �Qktr p <br />If yes, describe access - <br />Signature Q <br />Signature of Owner � Date: <br />0Q <br />Signature of Owner: Date: o <br />A Does parcel meet Zoning Requirements? Yes No n <br />R <br />> Does parcel require a Survey? Yes Ab <br />9 Permit application fees submitted? ❑ Amount S �UUr Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain:_ <br />Application .aCpp ed ! Denied Reason for Denial: <br />Land Use: / �� ~ Date: <br />