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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey Existing Parcel: 0.00/lot <br /> and/or Pre-Application Form <br /> Subdivision w/Survev: $200.00+$50.00/lot <br /> V <br /> ;� J //����f <br /> Owner: N✓1GQ f �/2>:At QF} 1Z�s6AJ a., elg5¢4L I-Ie7Afe- b <br /> Address: igl/al&14y44 Address: <br /> .714) �A-' �i+ 5`f�5 ST.G/1�/Jr 1'�/fLCS zu/ � o <br /> .��5 C l <br /> Phone: Phone: r 1 e�'7 9 �J <br /> Orizinal Parcei Inforniation <br /> Parcel ID#: 1,?6 3 Section :0 3 Township `TO Range /W/ <br /> a+a r ' Lv <br /> Original Description(or attach copy): , Of ael 1/ � i 4, a <br /> I-or <br /> .> Current Zoning: R2 Floodplain YIN: 1V Wetlands Y/N:_ N Lake/River Class: N a <br /> b •, <br /> Name of Water Body: N1/3 Shoreland Agreement/SIPS Y/N: /v <br /> o <br /> .. Farmland Preservation Y/N: � Managed Forestry Law Y/N: /y <br /> New Parcel Information p <br /> Proposed New Legal Description and Parcel Size: <br /> Tw 10,412 CGS INTO ON6 Lo% p <br /> 7 <br /> Acres: 301/ 4ozf5 <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: jC!S 1AJ4� AC6rgS -7-0 A.WC <br /> Proposed access to public waters to be provided Y/N: A.1 <br /> If yes,describe access: <br /> G <br /> Signature of Owner: Date: <br /> Signature of Owner: �/� 1 Date: a <br /> B <br /> Y Does parcel meet Zoning Requirements? Yes No <br /> N <br /> °o ➢ Does parcel require a Survey? �'es No <br /> G <br /> p J' <br /> °Q ix <br /> ➢ Permit application fees submitted? ❑ Amount$ � '0 Receipt <br /> U1 <br /> t. ❑ Reconciles with Real Property Lister Yes No Dat:c: <br /> m <br /> 0 <br /> ° If not,explain: <br /> M <br /> 0 <br /> a <br /> y <br /> Applicatio !Approvcd/ enied Reason for Denial: <br /> Land Use: 1 9 ZO 2� Date: <br /> D E IEodIE <br /> 2 10113 <br /> Burnett County <br /> Land Services Department <br />