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(nf�'C-0-01 f' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d0 71 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> s <br /> TG THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m J <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- w <br /> nett County LaInd Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n _I <br /> tljEsgjla -e �go� S K' / y , l <br /> , , <br /> a <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> Address Address <br /> City,State,Zip Code City, State, Zip Code <br /> / to I ],- - 4/6/ - 2� <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m »' <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: o ° <br /> (family ome/cabin, ra e,type of addition, etc.) <br /> r <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). o <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 ordi- <br /> nary high water mark of lake, river or stream, if applicable. M' <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. O <br /> 0 <br /> 3 <br /> PLOT PLAN IR N <br /> Z c <br /> o Q <br /> (L\ n <br /> V <br /> N <br /> 0 <br /> O <br /> 1 � <br /> �y a <br /> J l <br /> O <br /> n Y co <br /> ? <br /> 0 <br /> � VV p <br /> SCS S� 1est T7or prl„`Y <br /> 0 <br /> -rest <br /> 1 <br /> tro <br /> �� hoc Ste G oc� Fromm V) <br /> bon lO <br /> Z <br /> NI D <br /> 1 <br /> p In w M. o0acm <br /> w <br /> M.Wo 0 n c <br /> 0 m <br /> G wC 0 O 3 <br /> 0 j � O O o <br /> M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- (? o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I4a <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- [ i <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> / IWO <br /> SIGN HERE /712je � <br /> (sig e At ownr=but (date) (V ” o, <br /> o: o <br /> ZONING ADMINISTRATOR o: o <br /> o: o <br /> T <br /> S �N, 000 <br /> TOWNSHIP PE MITS MAY BE REQUIRED o 000 0o mm <br /> 000 oorn <br />