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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 or Map Review Form Subdivision w/Survey: $200.00+$50.00/lot <br /> Roy/ � 6 G ro <br /> Owner: /YI Buyer: <br /> Address: Address: <br /> Phone: Phone: <br /> Original Parcel Information ..0 <br /> Parcel ID #: Section ' / Township it0 Range / <br /> '/ O <br /> Original Description (or attach copy): G.O / 3 C.-514V t 2-49- <br /> a <br /> Current Zoning: Floodplain Y/4.4111C0--- <br /> N: — Wetlands Y/N: Lake/River Class: <br /> YellName of Water Body: -L vAJ1 ' (/a bLpi Shoreland Agreement/SIPS Y/N: <br /> t' Farmland Preservation Y/N: Managed Forestry Law Y/N: <br /> a <br /> New Parcel Information_ m0 <br /> Proposed New Legal Description and Parcel Size: J0i4 Com/ 1 6 I <br /> P r-- <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> T <br /> Proposed access to public road: �� <br /> Proposed access to public waters to be provided Y/N: <br /> If yes, describe access: <br /> b <br /> Signature of Owner: Date: Z <br /> Signature of Owner: Date: <br /> Y?' (mo <br /> / <br /> Does parcel meet Zoning Requirements? Yes No Cid^ ‘o3 7 \ <br /> N ➢ Does parcel require a Survey? Yes No <br /> D <br /> Permit application fees submitted? 0 Amount$ .52,, D� Receipt# <br /> 0 Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> a <br /> •t <br /> Application: 'pr e eReason for Denial: <br /> y Land Use: Date: <br /> eZ492.../ <br /> Ce9Pf %�s Q -f;1'L+.t_ cre owee, A,10 sf703 <br />