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i <br />Fccs (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: S50.00 <br />and/or Pre -Application Form Survey of sionExistingSrvercel: 550.00/lot <br />pp Subdivisionw/Survev: 5200.00+$50.00/lot <br />Owner: A u— f t-J p LL -1 C A L. F7 Buyer: <br />Address: 2 o Q S � Address: <br />Phone: t 1`~� Phone: <br />Original Parcel Information <br />(- <br />Parcel ID #: 1 -3O O <br />p� <br />3`' 1 Section i Township C Range <br />Original Description (or attach copy): <br />Current Zoning:'�-- _Floodplain l'!N: N/ <br />NVetlands Y/ati: IV Lak"iver Class: <br />Name of Water Body: <br />Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: <br />Managed Forestry Law Y/N: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: <br />C'jy C-- C� T C -� ✓�� <br />Acres: <br />(If parcel is to be surveyed, provide preliminary map. <br />See/ attached for preliminary map requirements.) <br />Proposed access to public road: E X ` "T I <br />ly Cr— CC S--, <br />Proposed access to public waters to be provided Y/N: <br />If yes, describe access: <br />Signature of Owner: - —t:C a +�. ( Date: s 1 I g <br />Signature of Owner: Date: <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? <br />)'es No <br />➢ Permit application fees submitted? ❑ Amount S Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Application: CApproved, <br />C U P (�P,0-MV <br />Land Use: <br />d Reason f r De ial: <br />Date: <br />n <br />0 <br />9 <br />c <br />A <br />