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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivisionw/o Survey: $50.00 <br /> Survey of 00/lot <br /> and/or Pre-Application Form Subdivisionw/Suryev: $200.00 <br /> +$50.00/lot <br /> Owner: /!Lehi 4 5&l—/ m Buyer: <br /> r ro <br /> Address: 120 Z Q L t // �-e, / � t /, Z4#6 ss <br /> 6`69A 3 #, &4' a 119ya z <br /> uo <br /> Phone: 15-7 � 3996 u <br /> Phone: _ <br /> 463L1-152_1-0q660 Oridnal Parcel Information 6 <br /> #d' -�5z1 - o y5o0 o56at n , r�� � <br /> Par�ID#: -*03y-/JZ/-055566 —Aj `y_i3,41 Section �t� Township-3;// <br /> Range 4 <br /> O <br /> Original Description(or attach copy): Q re /%V i 6% DA/ or Z-4-r / C 'j/n <br /> e <br /> VNI 1' IIN- I15 ! Lo7 Z Cpm V19 P 16&-/49 dAJd <br /> C' 51" V 6' D 2,17- 2,18 AVO 671fCle G4,4105 �. L. .3 <br /> F <br /> T Current Zoning: Floodplain YY N: / W�ettlands�}',lN: <br /> Lake/River Classification:_L46225—L. Name of Water Body: L/ /I l-e <br /> Shoreland Agreemt or SIPS Y/N:_Farmland Preservation Y/N: Managed Forestry Law YIN: ^ <br /> New Parcel Information / ry� <br /> Proposed New Legal Description and Parcel Size: ��m L f , V, a� �.?j7_ <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: V'U d <br /> m <br /> Proposed access to public waters to be provided Y V: 1-0C LOT„( <br /> If yes,describe access: J <br /> 1 <br /> o Signature of Owner: Date: <br /> e <br /> Signature of Owner: Date: o <br /> 3 <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> ?t <br /> 0 <br /> ➢ Does partel require a Survey? Yes No o p Q G <br /> a <br /> Permit application fees suburitted? ❑ Amount$ac)(D' D U Receipt# C <br /> ❑ Reconciles with Real Property Lister Yes No Date: s°o <br /> If not,explain: wh d <br /> p o00 <br /> 000 <br /> G Pr <br /> 011 <br /> a o' <br /> Application: Approved / Denied Reason for Denial: <br /> � J <br /> Land Use: Date: R207,-) _� <br />