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H� (P�ffVv,cz i C C o vv, <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 />PP Subdivision w/ Survev: S200.00 + $50.00/1ot <br />Owner: Tom and Marcia Nagel Buyer: <br />Address: 15569 110th St Address: <br />Leroy, MN 55951 <br />Phone: <br />Phone: <br />Oriy1inal Parcel Information <br />07-020-240-16-27-5 05-005-015000 <br />Parcel ID #: 07-020-240-15-27_5 05_O0.5-r? 16t7nn Section 27 Township 40N Range 16W <br />Original Description (or attach copy): Lots 12 & 13 CSM #3758 V19 P104 (FMLY CSM V17 P3) <br />(Gov Lot 5) <br />Current Zoning: R_ R-3— Floodplain Y/N:----N_Wetlands Y/N:_N Lake/River Class: <br />C- <br />Name of Water Body: ' Shoreland Agreement/SIPS Y/N: - J <br />Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br />New Parcel Information <br />I 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: _ G '1 L'` ( Date: <br />Signature of Owner: ' 0'k-, ', GLCL`f` (C• Date: <br />➢ Does parcel meet Zoning Requirements? Yes No RcL ZG 19 <br />� ➢ Does parcel require a Survey? Yes No <br />- 6001-7 <br />a° ➢ Permit application fees submitted? ❑ Amount $ 100, <br />Receipt # <br />m ❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />0 <br />Applica"iwC Approved / Denied Reason for Denial: <br />0 <br />e <br />A <br />J <br />C% <br />C� <br />