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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/Survey: $200.00+$50.00/lot <br />Owner: ROXA Nf JC UZU 04,U 1 Buyer: <br />Address: 4-1 EAST Ce ALL 80412 c APr2h Address: <br />�' u <br />Phone: &12--91;6- 1739 Phone: <br />Original Parcel Information <br />Parcel ID #: c4•pCO-011 pp Section—LL—Township 36 Ranged <br />Original Description (or attach copy): r'kE Sc+i. r& 4.dgo' pF 1-46 We, z 33y' DF Tgc- c44r 99o' <br />or- Lae 5,odTVE,46r j2iJ4ArE2 tV ME AjvlZn_ eA" r t9uAj�%r_jt <br />Current Zoning: A 2 _Floodplain Y/N: N Wetlands YIN:YLake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: N <br />Farmland Preservation Y/N: N Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: LCE 2 ©1= NEW C iM <br />Acres: tj , 00 <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: F.I jr,n1G D121✓S W4 I/ To' T04 -to NG1_SontD�EAeMa4q I7eaG <br />Proposed access to public waters to be provided Y/N: No. 3`�3.3Z9 <br />If yes, describe access: <br />Signature of Owners L4niY}�,�,,,�_�1�-- Date: 7— 7— <br />Signature <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? <br />Yes No <br />Permit application fees submitted? ❑ Amount $ Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, <br />Land Use <br />Reason for <br />�/ 3 // 20/ 9 Date: <br />14- <br />-4 - <br />CS -4- <br />