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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: $5O Mot <br /> Land//or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: oRo��beGrt a /ITL' Buyer: <br /> Address: Q07J Old` Address: 3 <br /> lAv�,(rz tri,, �U� �y893 <br /> Phone: Phone: <br /> Original Parcel Information ,/��� <br /> Parcel ID#: �f0 �7 ' 403�G Section 12- Township 3N Range / ',/ <br /> 71'✓ <br /> O <br /> Original Description(or attach copy): .266 Al <br /> e <br /> z <br /> a <br /> 10 <br /> Current Zoning: �� Floodplain YO Wetlands Y? <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y Farmland Preservation Y Managed Forestry Law Yb <br /> : <br /> A <br /> New Parcel Infornmation n Q <br /> Proposed New Legal Description and Parcel Size: t��m' a <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map.See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/� n <br /> If ves,describe access: S <br /> �O f.� <br /> c Signature of Owner: � Date: C>Q <br /> a <br /> Q° Signature of Owner: Date: <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ➢ Does parcel require a Survey? Yes No <br /> a — <br /> Permit application fees submitted? ❑ Amount$ 3 00, 00 Receipt# d U l <br /> o W <br /> a ❑ Reconciles with Real Property Lister Yes No Date: 4- <br /> w <br /> If not,explain: o <br /> W <br /> 0 <br /> 0 <br /> Application: pprove Denied Reason for Denial: o <br /> Land Use: Date: <br />