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Permit' o 'e_s(must accompanC form). <br /> - Burnett T;P3t Subdivision Application .. srloSnney SO.OQ <br /> ' Su"rrcyotorF:tingrarc.J Ss0.60i10 I <br /> § <br /> :t aIA' of s ..Application Form SubditisionwlSurvev. 5260.00 S'UiM1,, <br /> Jobn a rd Deborah Kielkucki <br /> Owner: - -- I3nyer. ro <br /> Address: 31,070 N Des Manes Lake Rd Address: CI <br /> 7, <br /> 1 Danbury`..".1154830 p <br /> 6'2-910 351 or 3060 <br /> Po <br /> Phone: phone: <br /> I ...> <br /> Original Parcel Information <br /> Parcel ID#: C.7-035-2-41-14-2E-2 Township 4 1 N Range ` r <br /> .0-^0 011 CCC Section 28 14 J. <br /> c t <br /> Original description for attach copy}: SE-IN Vi _ <br /> m <br /> RR1 <br /> .. <br /> r <br /> Current Coning: „Ftoodplain YIN: I\I Wetlands YIN: Y I.akelRivor Class: <br /> Name of WaterBody: NI Shoreland Agreement/SIPS YIN: <br /> Farmland Preservation Y/N: N :Managed Forestry Law V.N: N <br /> } a <br /> New Parcel Information <br /> Proposed New I.egal Description and Parcel Sire: CSM Subdivision <br /> I i k7 <br /> Acres: <br /> Ii if parcel is to he surveyed,p:oeide preliminary map. See attached for preliminary map requirements.) CJ <br /> S i Proposed access to public road: ' c-.' <br /> d <br /> `` Proposed access to public waters to be provided IPS: ? <br /> .Y i If y es,describe actc.s-: <br /> ..--':--e-- St�� 1 ti � �U " ,Signature of Oss nrr . ✓!,_ / Date: " . <br /> f. <br /> Signature of Owner .e- --sst. ---,7- <br /> Date: v�{ "-C� o <br /> __ _ <br /> r <br /> r Due,pu eimeellming quircmoas' yes No rt$ z; - <br /> °e i .1 Does Tame!requra aSwnevr res No <br /> 4431- - ',jt 2 <br /> i '17: I > a <br /> Pcr.nr•..f.�(%et..on fees nrt mrtrerl:' ❑ . o:- ni w - a.-,,-i...,r `. <br /> s, <br /> — _Recepl r�x �� Y�� �. <br /> i i A Reconciles with Real Property Lister Yes <br /> No Dater„7-2 <br /> If not esplain. r d <br /> ... � `e•`f \ <br /> ILJ <br /> Applicant n. Apprm ed Denied Reason for Denial:___ — — X7-7 i; <br /> d _tet <br /> — eta p <br /> Land lyse: f ; ` <br /> -- Date: a ,a <br /> } �y <br /> • <br /> 10'` <br /> N <br /> W <br /> , <br /> A 1/(4/ 000 Z._2_ /44-44— <br /> use o��Q�� � ) t� U/fR�c70 ° <br /> ' »✓a7- co a d es; t?14 �u /KGoHH ec7rovI o-F f C.� <br />