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Fees (must accompany form): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />and/or Pre -Application Form Subdivision w/ Survev: S200.00+$50.00/lot <br />Owner: Gerard & Amy Payne Buyer: <br />Address: PO Box 76 Address: <br />Taylor Falls, MN 55084 <br />Phone: 651-387-2925 Phone: <br />Original Parcel Information <br />Parcel ID #: 07-012-2-40-15-07-5 05-009-012100 Section 07 Township 40N Range 15W <br />Original Description (or attach copy): Lot 11 CSM V25 P302 (Gov Lots 8 & 9) <br />Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: N Lake/River Class: - <br />Name of Water Body: Ham Lake 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: 2 lot CSM dividing existing parcel <br />Acres: 2.14 <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 />➢ Does parcel meet Zoning Requirements? <br />➢ Does parcel require a Survey? <br />Permit application fees submitted? ❑ <br />❑ Reconciles with Real Property Lister <br />If not, explain: <br />A <br />se: <br />Date: <br />Date: <br />Yes No <br />Yes No p <br />/00, J 88'8'2- <br />Amount $ ,26( Receipt # e /1?51 p <br />Yes No Date: <br />Denied Reason for De al: <br />6h,9Ao <br />Date: <br />Land Services <br />19 <br />�� <br />C7 <br />U.1 <br />