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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: $50.00flot <br /> and/or Pre-Application Form Subdivisionw/Survrev�: 52.000..00+$50.00/lot <br /> Owner: DaM61 6U1r0 /pp Buyer: � ad5 <br /> )4 <br /> LD U7 j9& .y <br /> Address: ZZo7l, Croaked COEr lAdress: 91613 1 a5T71 AVE .5 Er 3 <br /> PI-m-c e�T4 , rhn/ �5D63 Bf�u�e2, mnl 55308 <br /> Phone: 2735y 5rbNE ,eoAD Phone: J <br /> ,7-OZD-Z-46- /6-3e, 3 Original Parcel Information O0 <br /> 0/-gyp-- 0 11100 <br /> Parcel IDI-Ir <br /> 020- 2- 46-/&-315-3 Section 35 Township /�t" Range <br /> 01 -000- 60 <br /> Original Description(or attach copy): - 6-1'020-7-"4b- <br /> W/z M VZ_ til , z. PV <br /> v Current Zoning: A— Floodplain Y& Wetlands `meg <br /> Lake/River Classification: Name of Water Body: P z A <br /> Shoreland Agreemt or SIPS Y4E _Farmland Preservation Y&_Managed Forestry Law Y(SL-_ <br /> New Parcel Information 3 <br /> Proposed New Legal Description and Parcel Size: L 5 M <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: A w, CQMdole6 /SI- KE C <br /> Proposed access to public waters to be provided Yk. 2ott O <br /> J <br /> If ves,describe access: U <br /> 0 <br /> c Signature of Owner: ^ Date: J o� <br /> 0 <br /> Eay•d9 <br /> °Q Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ➢ Does parcel require a Survey? Yes No �o <br /> a o � � <br /> Permit application fees submitted? ❑ Amount S Receipt# Z b o <br /> � NNS <br /> y <br /> ❑ Reconciles with Real Property Lister Yes No Date: 4 <br /> R 6 <br /> If not,explain: v <br /> wWw <br /> ° oo <br /> g g o <br /> obC" <br /> Application: Approved / Denied Reason for Denial: o s o <br /> 00 c <br /> Land Use: Date: <br />