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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />and/or Pre -Application Form Survey Existing Parcel: S50.00/lot <br />pp Subdivision w/ Survcv: 5200.00 + S50.00/lot <br />Owner: y> (R — C`�l 1q Buyer: L'IJPO i,� <br />n <br />Address: Address: <br />Phone: O 6 Phone: <br />Original Parcel information <br />ParcellD#: t77-Dad-,.;I.yt)-Ife-�1g-� 01.000-011(Y)L Section Z; Township 46 Range <br />0 Original Description (or attach copy): Z A)EN w <br />Current Zoning: A Floodplain Y&. WetlandON: Lake/River Class: <br />Name of Water Body: 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: Z Go7- C'J''72 l� <br />Acres: 00 <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: r� Date: Zi <br />of Owner: �i(f� <br />Date: 1-1-I9 <br />o <br />I <br />-Signature <br />> Does parcel meet Zoning Requirements? <br />Yes No <br />v <br />04 Ca <br />> Does parcel require a Survey? <br />Yes No <br />5' <br />0° <br />> Permit application fees submitted? O <br />Amount $ Receipt # <br />❑ Reconciles with Real Property Lister <br />Yes No Date: <br />G <br />a <br />If not, explain: <br />a <br />� <br />N <br />O <br />a <br />r <br />o <br />C <br />Applicatio pproved / enied Reason for Denial: <br />3 <br />ca <br />C <br />Land Use:L __ -_ ,� ..------__ <br />23 ?1�/,9 Date: <br />MV <br />