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10 <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: S50.00 <br />and/or Pre -Application Form Survey si Existing Parcel: 0.00 clot <br />pp SubdivisionwiSurvev: $�'00.00+$50.00i(ot <br />Owner: �) i 'lx,i �5 fC it A, ,j .^ rU Buyer: <br />Address: 1 r c t+-` Z a}_ Address: <br />Phone: i , 1 - 3 r Phone: <br />Original Parcel Information <br />Parcel ID #: b-?. _ 2 -1� �_ t�_•b �._c, r. , t .,! .D ,,:,Section 5,P Township el Range <br />Original Description (or attach copy): F e A -IT b A <br />a <br />Current Zoning: P-L Floodplain WN: _Wetlands Y/N: Lake/River Class: <br />A <br />Name of Water Body: ,,,r^ LGs i_A, i�f Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: Li , I +.tea t4 l -i A I <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: 3—, 1) FU s LA lLY T-a. ,k, r� <br />Proposed access to public waters to be provided Y/N: 's <br />1 <br />If yes, describe access: P tm S LA iz <br />Signature of Owner: t1�_nA, a j- - 4 <br />Date: <br />Signature of Owner: <br />Date <br />Does parcel meet Zoning Requirements? Yes <br />No <br />9 � <br />Does parcel require a Survey? Yes <br />IVo <br />� <br />°Q <br />Permit application fees submitted? ❑ Amount S <br />o� <br />300, <br />Receipt # <br />r.. <br />❑ Reconciles with Real Property Lister Yes No <br />Date: <br />y <br />° <br />7� <br />If not, explain: <br />A <br />`1 <br />Application: proved / 6enied Reason for Denial: <br />Land Use: _ _ lc�� -- <br />Date: <br />3 / <br />b <br />rt <br />2 <br />O <br />M <br />0 <br />r-/ <br />W. <br />