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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: $50.004ot <br /> and/or Pre-Application Form Subdivisionw/Survev: $200.00+$50.00/lot <br /> Owner: 1n)n rr e n N ceb"e Buyer: .ty <br /> Address: _�3 0 4-i lel a W,,o,A 3 S Address: <br /> z <br /> si"Q , �.,r stis-7z <br /> 0 <br /> Phone: -i m 5 - e, 5 3 - z z N 4 Phone: In <br /> Original Parcel Information <br /> Parcel ID#: Ee e z 4 z -7 e 1 1 o 0 Section 3,-7 Township 3 p Range <br /> O <br /> Original Description(or attach copy): e w - N3 w <br /> .^. <br /> o QS <br /> e Current Zoning: A 2 Floodplain Y/CWetlands YC (b <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Aareemt or SIPS Y Farmland Preservation YIN: Manaeed Forestry Law Y/N: , <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: Loi- 1 c s rn V. a <br /> Acres: C-r�, 4 .mti <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: AA niO <br /> A <br /> Proposed access to public waters to be provided Y/(p 1 <br /> If ves,describe access: 1 <br /> ki <br /> N Signature of Owner: Date: O <br /> o°o Signature of Owner: Date: c <br /> a ' <br /> Does parcel meet Zoning Requirements? Yes No OK *v l'^- <br /> m ➢ Does parcel require a Survey? es No <br /> c / <br /> D Permit application fees submitted? Amount$ a�.a� Receipt# _ <br /> ❑Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> C) <br /> rV <br /> LlJ <br /> 23 2012 a MAY <br /> Applicatio Approve '/ Denied Reason for Denial: <br /> Land Use: Date: <br />