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10/2023 Date Application Fee: $150.00 Paid APPLICATION FOR SINGLE LOT SUBDIVISION Clay County Planning & Zoning 3510 12th Avenue South, PO Box 280, Moorhead, MN 56561-0280 Ph: [PHONE REDACTED] / Fax: [PHONE REDACTED] Current Property Owner(s): Mailing Address: Street/Box Daytime Phone Cell Phone Applicant(s): (if different than Mailing Address: Street/Box Daytime Phone Cell Phone Location of Property: Township: Range: ________Section: Quarter:_______ Tax Parcel ID# (parent parcel): _ _ _ _ . _ _ _ _ Acres in Existing Name of Approximate size of new lot (in Intended use of *Will the new parcel need a new address assigned? (please circle) YES NO Source of Water Supply Method of Sewage List any existing Will the lot be located within 1,000 feet of a lake or 300 feet of a river/stream If yes, list name of lake, river, or Will new parcel be: (please circle) SOLD RETAINED** **If retained, please complete and file an AFFIDAVIT Surveyor’s Certificate (survey) with Corner Documentation IS required. Please submit a sketch plan of the new lot if a survey has not been completed. An aerial view of the land can be provided by the Planning Office. Name of Surveyor or Owner’s Signature: Date: Completion of parcel split will require the following: Completed/signed Application; Application fee; Survey; Sale deed or completed Affidavit; current year taxes paid in full on parent parcel. ---PAGE BREAK--- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Office Use Only Administrative Approval is: ( ) Granted. ( ) Granted subject to the following conditions: ( ) Denied for the following reasons: Issued by: Dated: