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Burnett County Subdivision Permit Application <br />Fees (must accompany form): <br />and/or Pre -Application Form or Ma Review Form <br />1� <br />Subdivision w/o Survey: $50.00 <br />1�1� <br />Survey of Existing Parcel: $50.00/lot <br />New Parcel Information 114:ma)O a <br />Subdivision w/ Survev: 8200.00 + $50.00/lot <br />Todd Hollenkamp <br />Owner: Buyer: <br />9187 Apple Road <br />Address: Address: <br />Pine City, MN 55063 <br />z <br />0 <br />763-267-8410 <br />Phone: Phone: <br />Original Parcel Information <br />Parcel ID #: 030 2303 08700 Section 3 Townshie 38 Range I `i <br />Original Description (or attach copy): CSM No. 3763, V.19, p.115-118 <br />Current Zoning: RR -1 Floodplain Y/N:___Y_Wetlands Y/N: Y Lake/River Class: <br />C�_ <br />Name of Water Body: Clam Lake Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: N Managed Forestry Law Y/N:' <br />New Parcel Information 114:ma)O a <br />, <br />Proposed New Legal Description and Parcel Size: This lot will be divided to create two new <br />lots of about 1 acre each along the north line between the lake the road. <br />The balance of the land will remain as a lot. Acres: 1A + 1A + 19.5A <br />(If parcel is to be surveyed, provide preliminary map. See attached for preliminary map requirements.) <br />Proposed access to public road: Direct Access to HideawayRoad <br />Proposed access to public waters to be provided Y/N: N <br />L� <br />If yes, describe access: <br />Signature of Owner: Z Date:OZ <br />wgnature of towner: Irate: <br />n <br />V <br />a <br />➢ Does parcel meet Zoning Requirements? Yes No <br />M <br />t <br />➢ Does parcel require a Survey? 1"'Yes,1 No <br />o� <br />Permit application fees submitted? XAmount $ 3 -Receipt # <br />❑ Reconciles with Real Property Lister Yes No Date: <br />If not, explain: <br />Applicati : Approved / enied Reason for Denial: <br />Land�]Use: s z3 Z -' Date: MAY 16 2017 <br />A <br />/ <br />7/l ND Uhd t�' Ylc t� �c� - <br />tvI L&-ra ;A 9. <br />tw <br />'1 r <br />