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Fees(must accompany torm): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> and/or Pree, Apjplicm//ation ForSubdivision w/Survev: $200.00+$50.00/tot <br /> -rlOwner: �l �4" Djgw. fe A-aTe.0/ �OC <br /> Address: - C%�Cl �/ /` d 5Q/77 Address: �n�� S 7tL� S <br /> Is ►vb-�; Ali yu 1 r�Ni DN <br /> Un 507/ <br /> Phone: �l 6 5 �o �� Phone: <br /> Parcel Information <br /> UV—0/30400 <br /> 22 LJ <br /> Parcel 1D#:#U?"C��Z'Z� I' --� - Sion "'Q-3 Township /IN Range �L✓ VV <br /> Original Description(or attach copy): 7 <br /> L at C'SmV / .? f'Sy C 5 b1/ >eC /l/ f IV6AIe9/ k& 3 <br /> b for 05m Vl5 10120 /v 6: wuJ <br /> 7 Current Zoning: Floodplain Y�Q ) Wetlands Y6 T <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y/6t. Farmland Preservation YQ_Managed Forestry Law Ytq_ <br /> New Parcel Information (n S <br /> Proposed New Legal Description and Parcel Size: am <br /> n <br /> Acres: /d• `1/o <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: 1 • �. 5 <br /> d <br /> m <br /> Proposed access to public waters to be provided ° <br /> tU <br /> If ves, describe access: <br /> Signature of Owner: Date G <br /> Signature of Owner: Date: e <br /> 3 <br /> ➢ Does parcel meet Zoning Requirements? Yes > No z <br /> o ?t <br /> ➢ Does parcel require a Survey? Yes No <br /> as � <br /> UJ j(j <br /> ➢ Permit application fees submitted? ❑ Amount$ 8(]0, OU Receipt# 9) i <br /> rW <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> � Wi <br /> a <br /> If not,explain: o O <br /> J <br /> � � O <br /> Application ApproveDenied Reason for Denial: <br /> Date: <br /> Land Use: — <br />