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Fees(must accomparry form): <br /> Burnett County Subdivision Permit Application Subdivision w/aSurvey: $50.00 <br /> and/or Pre-Application Form Survcysion of w SurvP : S 550.0+S5 <br /> pp SubdivisionwlSurvcv: 5200.00+350.00/lo( <br /> �. .>I � IR <br /> Owner: L0-E�-4CL'f 'L �(2�1— Buyer: <br /> v <br /> A <br /> Address: lv pp'R S T t C1�)fi�fy Address: <br /> Lt.) 4- <br /> Phone: Z `Y" 754 4� Phone: <br /> Ori¢inal Parcel Information <br /> Parcel ID#: Z`� Section 3 Township Rangc( i O <br /> Original Description(or attach copy): @ <br /> z <br /> Current Zoning: Floodplain Y/N:__Ay�_Wetlands YIN: Lake/River Class: <br /> aName of Water Body: r Shoreland Agreement/SIPS YIN: <br /> Farmland Preservation Y/N: Managed Forestry Law Y/N: �J <br /> New Parcel Information y <br /> Proposed New Legal Description and Parcel Size: t- S AA, I `<'J- Y C_ <br /> 1_6 T z- <br /> Acres• <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: G X \, ( fJ (b (L) L� S tv <br /> Proposed access to public waters to be provided YIN: <br /> If yes,describe access: <br /> Signature of Owner: < Y Date: -,4W2 <br /> Signature of Owne Date: �1 o <br /> S <br /> c <br /> ➢ Does parcel meet Toning Requirements? Yes No <br /> N u � <br /> o ➢ Does parcel require a Survey? Yes No <br /> Q4 ➢ Permit application fees submitted? ❑ Amount S t H 417D <br /> t. ❑Reconciles with Real Property Lister Yes No ' Date: <br /> .................. <br /> _ <br /> m <br /> 0 <br /> If not,explain: <br /> R � <br /> o E <br /> H' <br /> Applicatio . Approved ! Hied Reason for Denial: <br /> Land Use; rate: z© <br /> V <br /> E Di <br /> F ZB 2 0 2020 <br /> Burnett County <br /> Land Services Department <br />