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Fccs (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00ilot <br />and/or Pre -Application Form Subdivision $200.00+$50.00/lot <br />wiSurvev: <br />Owner: i lIAL_j9 �1i� ��,. r' Buyer: ti <br />Address:j t 1-1 ,t t t.: l�t�_ Address: <br />Z�h 2 3 6 <br />Phone: 1 • ? Fl - 3r I Phone: C. <br />Original Parcel Information <br />01 72.2.•t'li - 1� .Z,7.y t:y.4ti)3 -, -s2a ):. <br />Parcel fD #: --�_ a _ ! 1 <br />b �3 t- 2.-� t- t�-.a>�- : �: i .o/�ection '� Townships Range lam_ <br />_ <br />`. <br />0 <br />Original Description (or attach copy): .3 r a ; ., . al - <br />d <br />Current Zoning: +Per 'L Floodplain YIN:_Wetlands YIN: �i' Lake/River Class: <br />_ <br />Name of Water Body:. ; . vas LA i . g Shoreland Agreement/SIPS YIN: <br />Farmland Preservation YIN: Managed Forestry Law YIN: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: La, <br />w <br />a S 2.. 1,,,� ; Ar— t <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: S_I A Ft+ -ES tG i✓ 1, <br />Proposed access to public waters to be provided YIN: <br />If yes, describe access: ;. ; J S-^ P Lx, tz <br />Signature of Owner: , 1 ' (1 4 (ti �'' <br />b A.� q.,.- i._z_._ ~- � N'7` Date: S �. <br />Signature of Owner: <br />Date: <br />Does parcel meet Zoning Requirements? Yes No � w <br />Does parcel require a Sitrvey? Yes No <br />o B� <br />Permit application fees submitted 2 ❑ Amount $ 3 0C, Receipt # <br />t. ❑ Reconciles with Real Property Lister Yes No Date: <br />y <br />0 <br />° If not, explain: <br />0 <br />a <br />Application: proved / Denied Reason for Denial: <br />n <br />0 <br />e <br />!J <br />Land Use: <br />Date: <br />./ <br />