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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator d - o a <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m _ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 c _ <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n 1— <br /> tions of the State of Wisconsin. m o <br /> d1671IN- Q V/ L4AA10L61 F ii O <br /> OWNER(Please Print) Contractor or Surveyor or Agent o - <br /> s <br /> Address Address <br /> C19c-L4: SS014 J <br /> City,State,Zip Code City,State,Zip Code <br /> /2 12- 794--67Z-7 <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building X Filling/Grading t <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision 0 .`.' <br /> 0 <br /> Structure Use: 5R42 <br /> IL Lf(4 z Ifs <br /> (family home/cabin, garage, addition,etc.) 0 l� <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. <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. <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. 6. Provide legal land description. 0 <br /> 0 <br /> PLOT PLANI 3 <br /> TT o m <br /> EB Z a <br /> 0 a <br /> pq <br /> I � <br /> C <br /> Zv° T <br /> Ng 1a, Qs <br /> � 20 <br /> 'i Q E 40 l <br /> I <br /> �3 12 o <br /> m <br /> l � 1 <br /> Z <br /> 451 o Z <br /> D <br /> WATE MSR <br /> f L <br /> SS LA/t� 0 c�mmoa= <br /> n a < > o o n <br /> o y' imp mm3 <br /> m <br /> N S 2 m <br /> O <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m 1 c C <br /> PP (� 9 Y ) Y Y <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 further declare that I recognize that n ' O <br /> PP C 9 Y ) 9y ' a : <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <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 /> SIGN HERE <br /> y/ r /4—got <br /> (signature of owner orbuil contractor) (date) o o <br /> ZONING ADMINISTRATOR/ ' / <br /> n T <br /> TOWNSHIP PERMITS MAY BE REQUIRED u,u, m <br /> 0000 oCn <br />