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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision vr/oSurvey: $50.00 <br />Survey of Existing Parcel: $50.004ot <br />and/or Pre -Application Form Subdivisionw/Survev: $200.00+$50.00/lot <br />Owner: �ni RZ AC. Buyer: �r; nn� (yam )iS QczinAA .b <br />Address: t' R� Address: 2�0 t �lj C cl <br />Phone: Phone: _��_l_ _i �g 1- 00to C, <br />"3, <br />Original Parcel Information <br />Parcel ID#: o7-azt,-a-39-f5 aZ-5 0S_N2-a(j0cc Section O Township S9 Range <br />0-S <br />Original Description (or attach copy): Gnv Lo a C_k C SM \1 15 P(9U <br />=4 <br />L�a W a� \t&AV;e, RJO <br />r, <br />R <br />.a <br />v_ <br />Rf� <br />Current Zoning: Floodplair : Wetlands Y lei Lake/River Class: <br />' <br />Name of Water Body: SA k&_ Lt kr. Shoreland Agreement/SIPS Y ft-3 <br />Farmland Preservation Y • Managed Forestry Law Y( <br />` <br />C <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: CS/%I <br />Acres 4 t <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: vies <br />C7 <br />Proposed access to public waters to be provided S' N: La 1 t L.#- <br />1° <br />I <br />If yes, describe access: <br />l_1 <br />Signature of Owner: <br />,r <br />Date: <br />Signature of Owner: <br />�`— <br />Date: <br />c <br />➢ Does parcel meet Zoning Requirements? <br />Yes No <br />v <br />c <br />N <br />a <br />➢ Does parcel require a Survey? <br />Yes No <br />� <br />°Q <br />➢ Permit application fees submitted? ❑ <br />Amount $ a, <br />Receipt <br />r. <br />❑ Reconciles with Real Property Lister <br />Yes No Date: <br />0 <br />Q- <br />X <br />If not, explain: <br />n <br />G. <br />M <br />E C IE� V <br />y <br />Application: Apt /_Denied Reason for Denial: <br />;` �;J <br />f <br />Land Use / ��'' % c�'j Date <br />Burnett County <br />