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Received on: Fee: $200.00 plus $10.00 per lot Total Fee: APPLICATION FOR PLATTED SUBDIVISION (Rev 01/2021) Clay County Planning & Zoning 3510 12th Avenue South, PO Box 280, Moorhead, MN 56561-0280 Ph: [PHONE REDACTED] / Fax: [PHONE REDACTED] Phone Home: Box/Street Address: Phone Email: Name of Surveyor or Engineer: Location of Property: Township: Range: Section: How many acres in this parcel: Tax Parcel ID# (parent parcel) . . Will any lot be located within 1000 feet of a lake or 300 feet of a river/stream? If yes, list name of lake, river, or stream: Number of lots intended: Approximate size of lots (in acres) Intended use of lots: Source of water supply: Method of sewage: Are there restrictive covenants?: If yes, attach a copy Is there a zoning change contemplated?: If yes, describe the proposed change and area to be affected. Information requested by Zoning Administrator: Plat drawing in accordance with MN Statute Applicant’s Signature: Date: Page 1 of 3 ---PAGE BREAK--- If this plat is within Hawley Township, signature of Hawley Township is required before submittal to Planning & Zoning: Signature – Hawley Township Office Use Only Planning Commission Fee paid: Date paid: Hearing date: Preliminary approval is: ( ) Granted: ( ) Granted subject to the following conditions: ( ) Denied for the following reasons: Dated this day of 20 Chairperson, Clay County Planning Commission Page 2 of 3 ---PAGE BREAK--- Board of Commissioners Meeting date: Final approval is: ( ) Granted: ( ) Denied for the following reasons: x Dated this day of 20 Chairperson, Clay County Board of Commissioners Page 3 of 3