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elm <br />Fees (must accompany form): <br />Burnett County Subdivision Permit Application ON Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.00/lot <br />and/or Pre -Application Form or Map Review Form Subdivision w/ Survev: S200.00 + S50.00/lot <br />cell -7Is- qr 91 V 3 7,A,,K' <br />v� <br />Owner: aXro C eNt % Buyer: <br />Address:YWV YO K"tfO' _ ! Address: <br />!/ g P 7 S -ja-j t kc/ - 7�D <br />Phone: /11r V CIN? '47 1/®' ,11 Phone: _/ I S ` � 1P / `;� 3 [4 O"h 4- <br />Parcel ID #: <br />Original Parcel Information p <br />Section a 1 Township 3 Q Range o <br />Original Description (or attach copy): J -e t ol-f fu f r-I e J CC <br />LF <br />k1, <br />a <br />Current Zoning: Floodplaiin Y/N: !yU Wetlands Y/N: Lake/River Class: <br />Name of Water Body: � C' C.Q/ k' LIkf Shoreland Agreement/SIPS Y/N: Al C7 <br />Farmland Preservation Y/N: "f/ C) Managed Forestry Law Y/N: <br />60 rf )( New Parcel Information <br />C. <br />^,, <br />Proposed New Legal Description and Parcel Size: .�/ ")o L!Q- S4 4,-M rf <br />1 <br />6o,--,c/,V (,'o FS.2-* to fi?e .119,r-L o f � sc_,'d Prop ev ly w s <br />5 @ C i1 /.-7 7'k'L /,".L P cj-sc.r-Pf-ate, 6^ L/CW fi Acres: % C-7 fa, A <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />^lJ <br />Proposed access to public road: <br />Proposed access to public waters to be provided Y/N: '16/0 <br />If yes, describe access: <br />Signature of Owner: ,Lt�CJ-�/tiG�%C ' ;-�1.t0�a�1LG Date: q <br />Signature of Owner: ( cad 4/ CAX— Date: 1611c, <br />�C <br />➢ Does parcel meet Zoning Requirements? Yes No <br />➢ Does parcel require a Survey? Yes No <br />Permit application fees submitted? ❑ Amount $ Receipt # <br />C Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicati Approved / enied Reason for Denial: <br />Land Use: Date: <br />'�Z/9z11Vy <br />