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Fees(must accompany form): <br /> Burnett County Subdivisi®n Permit Application Subdivision w/o Survey: $50.00 <br /> nd/®IC Pre-Application Form Surveysionw of Survercel: $50.00/lot <br /> ..� Q � n,,/. �( '/ , /Sub/div/isionw/.Su/rvey:n$200.00+$50.00/lot <br /> / Owne� 0 /JlNdeA Bme er JU�T/V '�"/'Lf /VN�/` - d <br /> Address: OldMrf` Awt Address: 2W9!5 1?&0j55WJ /CO <br /> _ i((�Pu;Gt/tSh�dDy-33Zz Fx <br /> CeQto� inn/ 553p31 <br /> Phone: 219- 1v� 3- 3/ 5q 4gg4 Phone: ��6 � <br /> /- Q <br /> 0')q/0 Original Parcel Information <br /> � � ���Pat-eellD#; StTownship uQ/ / , <br /> Range& l <br /> �a Za-9zocti- oma .7_ QQ o <br /> Original Description (or attach copy): L-6-r5 / /J 16G� 9 <br /> �c.P�s u� 6'• y <br /> Current Zoning: Re Floodplait0/N: Wetlands <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y/_Farmland Preservation Y/6—Managed Forestry Law Ye— 4' <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: C' -4- <br /> Acres:Acres: <br /> (r <br /> (If parcel is to be surveyed,provide preliminary map. Seeattached <br /> for preliminary map requirements.) � <br /> Proposed access to public road: -PLUtitz` Slk-Q � d <br /> Proposed access to public waters to be provided YQ <br /> If yes,describe access: <br /> Signature of Owner: G Dater At ✓ d <br /> o <br /> Q0 <br /> Sig[ atureofOwne : Date: M•0 -40q o <br /> a <br /> ➢ Does parcel m t Hing Requirements? Yes No <br /> -c <br /> r ➢ Does parcel require a Survey? Yes No <br /> e p o <br /> Permit application fees submitted? ❑ Amount S :3Oo-(D b Receipt# i <br /> o <br /> ❑ Reconciles.with Real Property Lister Yes No Date: oro <br /> m , <br /> If not,explain: o <br /> a � <br /> ApplicatioC Approved / D lied ReasonforDenial: <br /> Land Use: Date: �� 13—1 <br />