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Sep 19 18 03:17p Clennan Anderson <br />n <br />7158338756 p,2 <br />F,,-,5 (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision wloSurny: $50.00 <br />ancUorPre-A lication Form Survey ofE?dstingParcel: 350.00,101 <br />I�p Subdivisiouw/Survey: S200.00t350M.flot <br />Owner: 0 w4 a <br />•. •C m..t.e .. • • on <br />�a da'irf W-1- sq is l <br />Phone: <br />ILVI WILAS <br />L \ <br />Original Parcel Information <br />Pa reel ID: cl-7_ o �b- 2 - 39 _! 5 o7$ -S o 5' i502 -a (i ! CO Section_aTownshiP Range_ <br />Original Description (or attach copy): Lo�_ {_ CSM V Q10 Prg -'�X- <br />Current Zoning: 'RR i Floodplain le—wetlands Y� Lake/River Class: <br />Name of hater Body:_ t/i Gi Shoreland Agreement/SIPS Y&_ <br />Farm]snd Preservation YI' Managed Forestry Law Y 1T <br />New Pa rc el Info rm a tion <br />Proposed New Legal Description and Parcel Size: CSM o4 - <br />Acres: C O , 5q <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Q X, <br />Proposed access to public waters to be provided <br />If yes, describe access: <br />Signature of Owner: <br />— - � � � � Date:�— <br />Signature of Owner: <br />➢ Does parcel nzeet <br />➢ Does parcel require a Survey? <br />iremenls? Yes <br />Yes <br />Permit application fees submitted? ❑ Amount S <br />Date: /'— �� -- /'L) <br />Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, <br />Applic <br />Land <br />Reason for Denial. <br />Da <br />1 <br />C> <br />00 <br />