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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />and/or Pre -Application Form Subdivision w/ Survev: $200.00+$50.00/lot <br />I j l <br />V �l <br />Owner: t Buyer: <br />Address: Address: <br />Phone: Phone: <br />Original Parcel Information <br />Parcel ID #: Section Township Range <br />Original Description (or attach copy): <br />Current Zoning: Floodplain Y/N: Wetlands Y/N: Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law YIN: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: <br />r <br />►^e, 15 l rn 9 o car <br />Acres: <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 Y/N: <br />If yes, describe access: <br />Signature of Owner: <br />Date: <br />Signature of Owner: Date: <br />);, Does parcel meet Zoning Requirements? Yes No G e— "�& <br />➢ Does parcel require a Survey? <br />)�' Permit application fees submitted? ❑ <br />Yes No <br />o� <br />Amount $ /322,1 Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />T.and IicPr <br />Reason for Denial: <br />I / 1 1 <br />0 <br />d <br />A <br />Vl <br />