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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: $50.00/lot <br /> and/or Pre-Application Form Subdivision w/Survey: 5200.00+MA/Mot <br /> Owner: David Grist Buyer: <br /> Address: 1075 Amundson Dr Address: <br /> Stillwater WI 55082 <br /> Phone: 651-208-2199 Phone: <br /> Original Parcel Information <br /> Parcel ID#• 07`020-2-40-16-11-5 05-001-012000 Section 11 Township 40N Range 16W <br /> Original Description(or attach copy): W 100' Of E 316 1/2' of Gov Lot 1 <br /> Current Zoning: RR2 Floodplain YIN: Y Wetlands Y/N: N Lake/River Class: <br /> -c <br /> Name of Water Body: Minnow Lake Shoreland Agreement/SIPS YIN: <br /> Farmland Preservation Y/N:N Managed Forestry Law YIN:N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM <br /> Acres: Oc. <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided YIN: <br /> if yes,describe access: <br /> Signature of Owner: /44/( iDate: I L/J <br /> 2/242 <br /> Signature of Owner: ` /J — /�^ Date: 11,1Z( 2.02D A <br /> Y Does parcel meet Zoning Requirements? Yes No <br /> ar Does parcel require a Survey? Yes No <br /> �- Permit application fees submitted? 0 Amount$ Receipt# <br /> t."" 0 Reconciles with Real Property Lister Yes No Date: <br /> ° if not,explain: <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />