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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: S50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+S50.00/lot <br /> Owner: Edward Simko Buyer: It <br /> Address: 1996 Langton Lake Dr Apt 219 Address: i3 <br /> K <br /> Roseville MN 55113 0 <br /> Phone: 651-636-2675 Phone: <br /> Original Parcel Information <br /> Parcel ID#: 07.028-2-40-14-13-5 15-432-037000 Section 13 Township4 ON Range 14W ` <br /> O <br /> Original Description(or attach copy): Lake McKenzie Beach Subdivision Lot 25, 26&27 Blk 3 <br /> Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: N Lake/River Class: <br /> Lake McKenzie N <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N- <br /> p <br /> Farmland Preservation Y/N:N Managed Forestry Law Y/N:N <br /> 0 <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM Combining 3 lots into 1 <br /> Acres: •61 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C <br /> m <br /> Proposed access to public waters to be provided Y/N: <br /> Cr <br /> If yes,describe access: <br /> , <br /> / - cry / <br /> Signature of Owner: Date:_ /d J 8 1 q <br /> Signature of Owner: r 1 Date: i D <br /> b <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> a ➢ Does parcel require a Survey? Yes No <br /> O <br /> 0 <br /> ➢ Permit application fees submitted? ❑ Amount$ �(� Receipt# L6)W <br /> t <br /> r. ❑Reconciles with Real Property Lister Yes No Date: <br /> m a. <br /> If not,explain: i <br /> � 3 <br /> 40 00 <br /> me <br /> Applicatio • pproved Denied Reason for Denial: E� <br /> ` c <br /> m <br /> Land Use: le /7 Z'e1 Date: <br />