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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/Jot <br />and/or Pre -Application Form Subdivision «/ Survev: $200.00 + $50.00/lot <br />Owner: Matthew Shaffer <br />Address: 3209 Dakota Ave S <br />Buyer: <br />Address: <br />St Louis Park, MN 55416 <br />Phone: (612)272-0506 Phone: <br />Orieinal Parcel Information <br />07-038-2-41-14-17-5 05-002-031000 <br />Parcel ID#: 07-038-2-41-14-17-5 05-002-034000 Section 17 Township41N Range 14W <br />Original Description (or attach copy): <br />PCL Gov Lot 2 EX E 735' and EX HWY Desc #406002 <br />Current Zoning: RR1 Floodplain Y/N: Y Wetlands Y/N: N Lake/River Class: - <br />Name of Water Body: Webb Lake Shoreland Agreement/SIPS Y/N: <br />Farmland Preservation Y/N: N Managed Forestry Law Y/N: N <br />New Parcel Information <br />Proposed New Legal Description and Parcel Size: New 2 lot CSM <br />Acres: 2.75 <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: �� Date: <br />Signature of Owner: Date: <br />i Does parcel meet Zoning Requirements.' Yes No <br />Does parcel require a Surve.0 Yes No 15716 <br />r Permit application fees submitted' ❑ Amount S Receipt # — <br />❑ Reconciles with Real Property Lister Yes No Date:_ <br />If not, explain:_ _ <br />V <br />Land <br />Reason for Denial: <br />Date: <br />