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oil <br />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: IgicaAAD K4r8Le,8 l [. xaI ya+4 Buyer: <br />Address: 1-34-I"i 1OWN NE44cM RoA0 Address: <br />5 i X81.1 lW 1 6 41312 <br />Phone: 116 - 220 14-6 q Phone: <br />Original Parcel Information <br />Parcel ID #: Section_Zk—Township 46 Range <br />Original Description (or attach copy): nft( E441- ! &Q' Ct= 174C- 4i 7U/fl•LA6r jW,4kPr6A DF 7146 <br />NORTRI54i.l- Quajr11: 5)(92 UA4 THE S,L7U-n4 &Lav►' <br />Current Zoning:A 7- Floodplain Y/N: t� _Wetlands Y/N:—" Lake/River Class: <br />Name of Water Body: Shoreland Agreement/SIPS Y/N: t.1 <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: M <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: L -o r 1 d t% LIG W Ui M <br />Acres: 9, q 9 <br />(If parcel <br />l iss to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed acl ess to public road <br />• 'To µnl n1 a4eN Roo 0 <br />Proposed access to public waters to be provided Y/N: N <br />If yes, describe access: <br />Signature of Owner: .-I'l Date: <br />Signature of Ownex f 7.li nti �� �� Date: 4Z - -2 <br />➢ Does parcel meet Zoning Requirements? Yes No <br />);, Does parcel require a Survey? <br />Yes No <br />Permit application fees submitted? ❑ Amount $ <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicatio Approved / Denied Reason for Denial: <br />Land Use: <br />Date: <br />Receipt # <br />4 <br />. :5 <br />0 <br />S <br />