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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: $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: Peaoe-Q wood s i-k)a l et_ Buyer: <br /> b <br /> Address: l�Oa5 f4-le Trct� �d Address: f OMPUTEPJSCANNZD <br /> z <br /> 6r-af)�Sbct W Z 5/8Lit <br /> Phone: Phone: <br /> Original Parcel Information <br /> 0'7-03 LI-a-3'1-1$-lI-S-O S-oos-011000 <br /> Parcel ID#: 0,7-o34-D-3,7-!$-)a-SOS o03-o tIOop Sectionl/ Township 50 Range <br /> O <br /> Original Description(or attach copy): <br /> Dom) a34` -3°?-(� l)- 5-�5-b05-ollUoo `60V L_0 5 <br /> 017 -u34 60V Lo+ 3 p <br /> 12-I, 1212 a, ro <br /> Current Zoning:02-3 Floodplain Y/N: �e,-5 Wetlands Y/N: Yes Lake/River Class: 5 <br /> > Name of Water Body: \J10l hI+ LaKe- Shoreland Agreement/SIPS Y/N: <br /> � 1 � <br /> Farmland Preservation YIN: LD Managed Forestry Law Y/N: <br /> o <br /> New Parcel CCInformation 4- <br /> Proposed New Legal Description and Parcel Size: y ee �IQ I Z��� P <br /> Acres: <br /> (If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: p <br /> m <br /> Proposed access to public waters to be provided Y/N: 2 <br /> If yes,describe access: <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: o <br /> 9 <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> z <br /> ➢ Does parcel require a Survey? Yes No o s <br /> a,ci <br /> °Q ➢ Permit application fees submitted? ❑ Amount$ Receipt# w w <br /> w � <br /> r ❑ Reconciles with Real Property Lister Yes No Date: ETC <br /> 0 <br /> If not,explain: y, <br /> o <br /> � N a <br /> a o <br /> Application: Approved / Denied Reason for Denial: ° O <br /> o <br /> c o <br /> O v <br /> Land Use: Date: <br />