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Burnett County Subdivision Permit Application <br />and/or Pre -Application Form <br />Fees (must accompany fonn): <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 />10V V)t <br />Owner: Aaw O C 4I 4" <br />r: �� 116r -ti / ���J_L 4YJK:5 <br />Address: 3 l�,F/��s'�=� f T Address: 12 3Cf_7 1 Z::Q(a LIQ 1 P <br />.J?49/�4 Ld <br />Phone: .� O - 2 - zYs'� Phone: <br />OriEinal Parcel Information <br />Parcel ID#: of -rnss--3Sr-fy-IFi.i o5•co9-cj310o SeJ�cttion I8 Township - U, Range /Q <br />Original Description (or attach copy): L DY If CJ)A >'l -72n Val /,f Pj 1-77V 12f <br />Current Zoning: R� 1 Floodplain YA@Wetlands Y,o1 Lake/River Class:,_ <br />Name of Water Body: Shoreland Agreement/SIPS Yr <br />Farmland Preservation Y4f1 Managed Forestry Law Y/91 <br />New Parcel Information J <br />Proposed New Legal Description and Parcel Size: 2 L ° f CSA f- s 'y i gL ►., <br />Acres: 516oig <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road:-Ckljflvvf <br />Proposed access to public waters to be provided YV <br />If yes, describe access: — <br />X Signature of Owner: <br />Signature of Owne .0 <br />➢ Does parcel meet Zoning Requirements? <br />Does parcel require a Survey? <br />Permit application fees submitted? ❑ <br />Yes No <br />Yes No <br />Amount $ 3D©' <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: <p roved enied Reason for Denial: <br />Land Use: <br />Date: %, Of —20/00 <br />c% A99_3 <br />A Cl - <br />Receipt # _ <br />/ z -2/e' <br />1p <br />S <br />