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Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 6T .-� <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. <br /> P ri 4 S J P <br /> a f <br /> OWNER(Please Print) Contractor or Surveyor or Aged o <br /> OT <br /> a-a. S /�or a 14U <br /> Address <br /> Address <br /> IQ stf O Mu t rf <br /> City,State,Zip de City,State,Zip Code 2S <br /> Telephone <br /> Telephone <br /> S / <br /> P <br /> Permit(s)Applied for: 1 <br /> New Building Filling/Grading <br /> Addition Moving o 3 <br /> Sanitary - — Camping Unit o ft <br /> Privy Subdivision H .`.- <br /> r <br /> o' <br /> Structure Use: Z <br /> (family homelcabin, garage,addition,etc.) o 'o <br /> v <br /> m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield(DF). — <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream -if within 300 ft. G <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river or stream, if applicable. 00 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. <br /> 0 <br /> PLOT PLAN 3 rn <br /> Z a <br /> N <br /> O <br /> JS v <br /> r <br /> A <br /> N N <br /> m <br /> n <br /> OD <br /> O <br /> 0 <br /> I <br /> lT <br /> Z <br /> fN <br /> p 0 N DDm-0 <br /> m c �.m 0nc <br /> o< � nn- m <br /> LD. <br /> 9 < <br /> N O O 3 <br /> 0M <br /> Z OO <br /> «€ m <br /> JQ cc A <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that O <br /> PP (� 9 Y 1 9 I ; o <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a [ o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> (D <br /> N <br /> SIGN HERE <br /> (sign�Ftir o} owner o ding contractor) (date) <br /> ZONING ADMINISTRATOR o; o <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED & m <br /> 00 6000 <br /> 00 5066(/ <br />