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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> e' and/or Pre-Application Form Subdivision w/Survev: $200.00+550.00/lot <br /> Owner: �V1II tQ/�7 t/��/ Buyer: ro <br /> Address: / 2d 0 Address: a <br /> Phone: ,I J� /)1 I Phone: �1 <br /> C� <br /> Original Parcel Information <br /> Parcel ID#: Section l Township V11V Range 16 yy' <br /> O <br /> for i e5mva8� ya3 ,�gi- qz <br /> Original Description(or attach copy): m <br /> a <br /> Current Zoning: �/\ Floodplain YQ Wetlands Y� 3 <br /> Lake/River Classification: Name of Water Body: <br /> Shoreland Agreemt or SIPS Y& _Farmland Preservation Y&_Managed Forestry Law Y4P�_ _ <br /> New Parcel Information o <br /> Proposed New Legal Description and Parcel Size: Af 'L/ V/ e-Y� �r <br /> Acres: fie. O O <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 YO <br /> If ves,describe access:4 <br /> c Signature of Ownerf/ - Date:6 �D `09 <br /> o v <br /> o <br /> Signature of Owner: - Date: 3 <br /> e <br /> ➢ Does parcel meet Zoning Requirements? Yes No <br /> —.- x <br /> ➢ Does parcel require a Survey? Yes Noo J 61, ag-cq o O <br /> Permit application fees submitted? ❑ Amount S C"6b'Uy Receipt# r N <br /> n N N <br /> o <br /> a ❑ Reconciles with Real Property Lister Yes No Date: <br /> s � <br /> N r' <br /> If not,explain: <br /> w <br /> 0 <br /> P i <br /> Applicati Approv / Denied Reason for Denial: 4 <br /> Land Use: Date: <br />