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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Esisting Parcel• $50.00/lot <br /> and/or Pre-Application Form or Map Review Form Subdivision w/Survey: $200.00+$50.00not <br /> H ro <br /> Owner. John Johnson Buyer: <br /> d <br /> Address:2017 80th Ave NE Address: �A ice,^_ A o <br /> Eyota MN 55934 <br /> �\N <br /> Phone: 7—(a, `"I O 1 Z�;' Phone: <br /> Original Parcel Information <br /> Tax 1D#: _ 07-012-2-40-15-11-5 15-72 -071000 Section 11 Township 40 Range 15 O <br /> 070000 069000 Tail Moon Add to W Lots 59-61 Original Description(oo r attach copy): <br /> m <br /> Current Zoning: PUS Floodplain Y/N:N Wetlands YIN: N Lake/River Class: <br /> e <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N: y Q <br /> Farmland Preservation YIN:N Managed Forestry Law Y/N: N y <br /> 0 U <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size. CSM to combine existing lots <br /> 0 <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 YIN: �\ <br /> v� <br /> If yes,describe access: <br /> Signature of Owner: Date: Z•�t _ Z' <br /> Signature of Owner: Date: <br /> Fee Rec: <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> Check#: <br /> ➢ Does parcel require a Survey? Yes No <br /> Reconciles with Real Property Lister Yes No Date: <br /> If not,explain: <br /> Application . Approved 'Denied Reason for Denial <br /> Land e• r( Date: <br />