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o <br />u <br />Fees (must accompany forni): <br />Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br />Survey of Existing Parcel: $50.001lot <br />and/or Pre -Application Form Subdivision w/Survev: $200.00+$50.001lot <br />Owner': 4A v imo KA th jsxc �QA ` -Buyer: W- K V -9 e l .a <br />Address: 12011 COPPFn filth • OLVP Address: • <br />C14412Lon" Ale_ 28277- 298- o <br />/ C <br />Phone: Phone: (olZ 2�0-Zg�jG � <br />Original Parcel Information <br />Parcel ID #: p 7- e32r 2-41OS-3 0.3 _oijD' C3lypt� Section S4� Tow//nship I I Range <br />Original Description (or attach copy): Ltf Z r �� �� P �q k 3 0 8l S <br />v3 Nw i4w aLs_ <br />Current Zoning: X 3'A' 11Tloodplair&N: / Wetlan j'/N: Lake/River Class: <br />Name of `Pater Body: Ts /GL.sC LG 4. Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y,6 1Vlanaged Forestry Law WIN: <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: 2 L �i` C.i �+ <br />Acres: J (D , 5 1D <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Y" <br />Proposed access to public waters to be providedoN: <br />If yes, describe access: t, a 4. <br />Signature ofOwner:; Cti<^2?i72� Date: <br />a <br />Signature of Owner: Date: <br />Does parcel meet Zoning Requirements? <br />> Does parcel require a Survey? <br />> Permit application fees submitted? ❑ <br />Yes NO <br />Yes No <br />w 18,5w <br />Amount S Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicatio Approved / Denied Reason for Denial: <br />Land Use: <br />Date: <br />h <br />110 <br />