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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 /> and/or Pre-Application Form Subdivision w/Survev: $200.00+$50.00/lot <br /> Owner: sysA,.1 Matte Buyer: b <br /> e� <br /> Address: Z`c 3_7 \ (-L Address: <br /> _ �? c. <br /> Phone: �t5 Z� Cl - 3z'{��(� Phone: <br /> Original Parcel Information <br /> oOO <br /> Parcel ID#: o'7-d 38 Z 4 I -14 -Zvi-Z U3' Section Zt Township Range , C <br /> Original Description(or attach copy): t-�f Z C�M 3BE Utz • "LO <br /> {� G <br /> .d Current Zoning: \\ Floodplain Y/N: ,AJ Wetlands YIN: P\) Lake/River Class: <br /> C <br /> Name of Water Body: Shoreland Agreement/SIPS Y/N: � <br /> Farmland Preservation Y/N: .) Managed Forestry Law Y/N: A-11 <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: <br /> Acres: <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 Y/N: / <br /> If yes,describe access: <br /> Signature of Owner: 'ILl'e Date: _ <br /> Signature of Owner: Date: <br /> ss <br /> Y Does parcel meet Zoning Requirements? Yes No <br /> 5� Does parcel require a Survey? Yes No N <br /> 5' nnI <br /> QM ➢ Permit application fees submitted? ❑ Amount$-31 Receipt 511K <br /> t., ❑ Reconciles with Real Property Lister Yes No Date: <br /> m <br /> L7 <br /> ° If not,explain: <br /> A <br /> O <br /> ■t <br /> y <br /> Applica ' n: Appro enied Reason for Denial: <br /> Land Use: �� �l Date: <br /> Lr-� IE <br /> D <br /> OCT t s 2019 <br /> Burnett County <br /> Land Services Department <br />