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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/Survey: $200.00+$50.00/lot <br /> Owner: Gary Mather <br /> Buyer: <br /> Address: 5920 Thomas Ave S Address: <br /> Minneapolis MN 55410 <br /> o0 <br /> c <br /> Phone: 612-860-5590 Phone: <br /> Original Parcel Information ] <br /> 1 <br /> Parcel ID#: 07-018-2-39-16-26-5 15-093-030000 Section 26 Township 39N Range 16W <br /> Original Description(or attach copy): Clam Lake Pines Lot 20 O� <br /> .14 <br /> t7 <br /> Current Zoning: RR1 Floodplain Y/N: Y Wetlands YIN: N Lake/River Class: <br /> 3 \ <br /> Name of Water Body: Clam Lake Shoreland Agreement/SIPS Y/N: <br /> Farmland Preservation Y/N: N Managed Forestry Law Y/N:N <br /> New Parcel Information <br /> Proposed New Legal Description and Parcel Size: CSM <br /> Acres: <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: <br /> Proposed access to public waters to be provided Y/N: f° <br /> If yes,describe access: <br /> Signature of Owner: ye77/eazvt,24, Date: <br /> 12/23/20 <br /> Signature of Owner: Date: <br /> 8 <br /> a <br /> ➢ Does parcel meet Zoning Requirements? Yes No �, <br /> N <br /> 1 <br /> a ➢ Does parcel require a Survey? Yes No <br /> 5. <br /> Q° ➢ Permit application fees submitted? 0 Amount$ Receipt it <br /> t,;) <br /> ❑ Reconciles with Real Property Lister Yes No Date: <br /> a <br /> if not,explain: _ <br /> A <br /> o <br /> C <br /> Application: Approved / Denied Reason for Denial: <br /> Land Use: Date: <br />