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-- Vv`� v i�er ! !c� ��c w�a i I ., C o wt. <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />and/or Pre -A lication Form Survey of Existing Parcel: $50.00/lot <br />AP Subdivision w/ Survev: S200.00 + $50.00/lot <br />Owner: _Tom and Marcia Nagel Buyer: ti <br />Address: 15569 110th St Address: <br />R <br />Leroy, MN 55951 0 <br />s <br />Phone: Phone: c <br />v <br />Orii(Onal Parcel Information S <br />07-020-240-16-27-5 05-005-015000 <br />Parcel ID #: 27 <br />1 <br />07-020-2-40-16-27-5 n5-nn5-n1 Fnnn Section Township 40N Range 16W >L <br />Original or attach >;i Description p ( copy):.. Lots 12 & 13 CSM #3758 V19 P104 (FMLY CSM V17 P3} <br />(Gov Lot 5) <br />Current Zoning: RR3 Floodplain Y/N:---N—Wetlands Y/N: N Lake/River Class: ' <br />Name of Water Body: ' Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />Signature of Owner: -,— <br />Signature of Owner: <br />Date: <br />Date: <br />➢ Does parcel meet Zoning Requirements? Yes No R�L t f r z& 1 <br />➢ Does parcel require a Survey? Yes No G C- > 60&,( -7 <br />O� <br />Permit application fees submitted? ❑ Amount $ 10,9, Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />L <br />Applica n: Approved / Denied Reason for Denial:_ <br />Land Use: Date: /—,O Z,,-21 <br />