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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Owner: B�. �_ e v e - <br />Address: <br />C <br />Phone: .5 Li — <br />Fees (must accompany form): <br />Subdivision Nv/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />Subdivision w/ Survev: $200.00 + $50.00/lot <br />Buyer:i ��«wt• lC e <br />Address: <br />Ys3 <br />Phone: Jam'- 2-0 - 2-0 <br />� <br />Original Parcel Information <br />Parcel ID #: !'`,j - (} 3 ' Lf� —(`� -?S - ij 03 - boSection' ZTownshi Range <br />( g <br />5 <br />Original Description (or attach copy): E x 1-A 3 ll1 c Nt 6x <br />'S <br />i n <br />Current Zoning:__Floodplain Y/N: �I l Wetlands YIN:_Lake/River Class: I?' <br />G <br />ro <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation YIN: Managed Forestry Law Y/N: <br />n <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: LCk C.SM <br />Acres: 5 • 1 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: 1V_ <br />Proposed access to public waters to be provided YIN: <br />If yes, describe access: <br />Signature of Owner: <br />Signature of Owner: <br />Date: <br />Date: <br />D Does parcel meet Zoning Requirements? Yes No ReC_ l t / ► 1 r , <br />Does parcel require a Survey? Yes No G�'V_ lea 9T! <br />�� <br />I Permit application fees submitted? ❑ Amount $ �C�O • �— Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicati . Approved / nied Reason for Denial: <br />Land Use: Date: <br />d <br />y <br />ro <br />�. <br />