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b- 1-3 <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50 0 <br />Survey of Existing ParcelAS-50.00/lot <br />and/or Pre -Application Form Subdivision w/ Survev: S200.00 + S50.00/lot <br />Owner: jj0_((e d\ `t 1xt\i g. j M o 5i c (' Buyer: .a <br />A <br />Address: Cv 315 /. � 11 � Address: 3• <br />\ z <br />L>cx�D�i c� Gy � S"�li33o <br />Phone: C45„7 - -j 5 (cam Phone: <br />Orieinal Parcel Information <br />Parcel ID #: (i t Q ? o2-yj-/(c 3& G.3 -6W. -- c�i?CW Section _3G Township yi Ranged <br />O <br />Original Description (or attach copy): l,,i `i C S M * P763 V <br />1.2 kof" 5" 65m ""06Y Vi Pdq,? j"-.23` OC& <br />Current Zoning:'R 1� ;Z Floodplain PNWetlands <br />Y V `., �Laks)River Class: <br />Name of Water Body: (Y- LI) 4---k '- <br />Shoreland Agreement/SIPS i(Z i <br />Farmland Preservation 1(%N') <br />Managed Forestry Law Y((N:; <br />_ <br />New Parcel Information 1� lam, __ <br />� � HCl Vi <br />Proposed New Legal Description and Parcel Size: ic9W1-hi <br />V <br />r`� ��7 4 o f y <br />r� <br />Ge <br />/ 4" 'f C5 <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 />r-� <br />Signature of Owner: <br />Date: <br />Signature of Owner: <br />> Does parcel meet Zoning Requirements? <br />> Does parcel require a Survey? <br />r Permit application fees submitted? ❑ <br />No <br />Yes No <br />m/ <br />Amount S <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, ex <br />Applicatiory!`- Approved,Denied Reason for Denial: <br />Land Use:;(--� _�-"" -- s1Z4 <br />Date: <br />Date: <br />Receipt # <br />BURNETT <br />W <br />