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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application speummvi w/o Survey: $50.00 <br /> and/or Pre-A licanon Form &trvcy of E"'*fluml. $50.00"°` <br /> PP SuMvision w/Ste: S200.00+sso.00nee <br /> , j Gyau�� wet <br /> owner: A K.L�p n 1 se-ma.- <br /> ',I b <br /> Address: / �' 71 At t Q L6 C,.7• Address: �o <br /> Phone: AP) <br /> � 4 21!- CI B Phone: �R 7.®s—c G <br /> •z--- CA <br /> 911&nal Pagel Infounadon � <br /> ©►_t� c <br /> • >►%� <br /> Parcel ID#: 0-7 6%&-2-39 - !�. - 6G_ 1 Section_ Township S 9 Range � <br /> Original Description(or attach copy): f-eT, <br /> 1S: C) -cat - Z-3q -tGa-0co-. 5 O " 1 011 <br /> Current Zoning: Z. Floodplain Y/N:___�_sWetlands YIN: T I,aketRiver Cis t: ca <br /> Name of Water Body: �IJ4 �.a c-V Shoreland Agneement/SIP$Y/N° <br /> M <br /> Farmland Preservation YIN- 1�1 Managed Forestry Law Y/N: <br /> _New Parcel Information <br /> Proposed NerwT,Legal Description and Parcel Size: 1_1�kX 4-- &o 7- <br /> Le,r' _ 9',�� L4:lr ' Z •5 A c. Acres: <br /> (If parcel Is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C u xle."f t _ 47t1VJ <br /> Proposed access to public waters to be provided YIN: <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: _ 1 1 <br /> -�=- Date:, - <br /> g <br /> 3' Does parcel meet Zoning Requirements? Yes N„ <br /> > Does parcel require a Survey? Yes Na <br /> Permit application fees submitted? ❑ Amount$ �? <br /> ❑Reconciles with Real Property Lister Yes No Date: <br /> If not, <br /> Application: roved / sled Reason for Denial: _ V <br /> Land Usc 7/ZG I Date- <br /> E ke'L-_3�" E0W <br /> Burnett County <br /> Land Services Department <br />