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Fees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00got <br /> Application and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.0011ot <br /> U2S 1< <br /> Owner: ( .(nfnC(_ 4J0_V G)ja✓1C'li7(_ Buyer: ,y <br /> Address: 6 a I �� D�G n C�e( 2 Address: <br /> S«eo VJI 6497a <br /> 71649f - lDIto w <br /> Phone: Phone: -C <br /> v <br /> OriOnal Parcel Information pQ <br /> Parcel ID#: 07-00 L-a-38"l 1 as 5 QS-003-01 iC0($ection a a Township Range r 1 <br /> O <br /> Original Description(or attach copy): A <br /> 6ou dot 3 Ex Porho� Luo 1�J of H-wWS5_ =6 -f acv <br /> 3 <br /> Current Zoning: Floodplain Y/N: N Wetlands Y/N: 'V Lake/River Class: <br /> o Name of Water Body: Shoreland Agreement/SIPS Y/N: CJ <br /> g <br /> m Farmland Preservation Y/N: 1 V Managed Forestry Law Y/N: �V <br /> New Parcel Information L! <br /> Proposed New Legal Description and Parcel Size: p <br /> (�6U Lo f EX 1909-4-2on Ltici Irt.i of 6!d 3�5a Ol r.-- V Ll &a-e <br /> E rA f J 1 A3,5 Acres: LID <br /> (If parcel is to be surveyed,provide preliminary map. <br /> See <br /> attached for preliminary map requirements.) <br /> Proposed access to public road: �•1 0(,a Y1 Gte /yam C <br /> Proposed access to public waters to be provided Y/N: A <br /> Hyes,describe access: <br /> Signature of Owner: Date: t <br /> Signature of Owner: Date: 3 <br /> F <br /> ➢ Does parcel meet Zoning Requirements? Yes No ti <br /> ➢ Does parcel require a Survey? Yes No 0 <br /> °O ➢ Permit application fees submitted? ❑ Amount$,5-6, y'-) Receipt# s <br /> SU <br /> Reconciles with Real Property Lister Yes No Date: <br /> m - <br /> L If not,explain: v <br /> o �^ <br /> n <br /> Applicatio Approved enied Reason for Denial: <br /> 0 <br /> �1� <br /> Land Use: �. Date: <br />