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Fees(must accompany form): <br /> Burnett County Subdivision Permit Application Subdivision w/o Survey: $50.00 <br /> and/or Pre-A lication Porm SureyofExisingP rcel: 0.0+$5 <br /> pp � Subdivision H;Survey: $2000.00+$50.00/lot <br /> Owner: Gerald Helmin Buyer: I <br /> evev <br /> Address:6486 Cherokee Tr Address: 3 <br /> Eden Prairie MN 55344 fkh <br /> c <br /> Phone: 612-269-5158 Phone: Zzi <br /> Original Parcel Information O <br /> Parcel ID#: 07-018-2-39-16-26-5 15-093-029000 Section 26 Township 39N Range 16W Q <br /> Lake Pines Lot 19 <br /> Original Description(or attach copy): Clam = <br /> A <br /> V'. <br /> Current Zoning: RR1 Floodplain YIN: Y Wetlands YIN: N Lake/River Class: 1 ..t <br /> m Name of Water Body: Clam Lake 3 d <br /> • y: Shoreland Agreement/SIPS Y/N: <br /> Ro Farmland Preservation Y/N:N Managed Forestry Law Y/N:N <br /> New Parcel Information <br /> 3. <br /> Proposed New Legal Description and Parcel Size: CSM <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: C <br /> Proposed access to public waters to be provided Y/N: `•° . <br /> If yes,describe access: <br /> Signature of Owner:.,,A' 3C /i�t�2� �Zl�t�u Date: lo`73/Z ..%) <br /> J / �7 <br /> Signature of Owner: Date: c <br /> 9 <br /> e <br /> D Does parcel meet Zoning Requirements? Yes No io <br /> N <br /> > Does parcel require a Survey? Yes No <br /> cra > Permit application fees submitted? ❑ Amount$ __Receipt# N <br /> t., ❑ Reconciles with Real Property Lister Yes No Date: • ') <br /> v <br /> e <br /> c If not,explain: <br /> o <br /> a <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />