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�,; �.,,-. .I <br /> Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> w o <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- m m O <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. - o <br /> N d <br /> CNt%CK '6ZW5NR(JpDc�Zl[k �pPkafx a = o <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> AQ -70 NWH 5 ND, 1 "- <br /> Address Addr s <br /> LilEP�%tcl w i Sy 8R3 cad �STe w I S y y13 Z <br /> City,State,Zip CodeCity,State,jip Code C <br /> Telephone Telephone 1 <br /> Permit(s)Applied for: (� <br /> New Building Filling/Grading <br /> Addition Moving _v, 0 <br /> Sanitary Camping Unit o n <br /> Privy Subdivision 0 ,`.- r <br /> U I d6 5tlJ E a c <br /> Structure Use: v (,, <br /> (family home/cabin, garage,addibbn,etc.) o ao <br /> Directions for plot plan drawing: N .� <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. IQ O <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. .I <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by V� <br /> the owner. p <br /> O <br /> 0 <br /> PLOT PLAN 3 <br /> v N <br /> Z a <br /> o a <br /> GSJ <_ <br /> G 5 � <br /> S <br /> fj ]S <br /> UI G <br /> Z <br /> Z (n <br /> 7J <br /> N <br /> t <br /> o _ <br /> T <br /> N <br /> g o <br /> Z <br /> m c m o ac"'o <br /> n Q m <br /> LDar - m =am <br /> N O J AO <br /> 9� m <br /> 0, c n ' O <br /> _8i ; c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all (P m <br /> information contained in this application(includingan accompanyingschedule and I further declare that I recognize that (� A <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 m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized I <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE RhLak <br /> _ <br /> (sign re F owner or bu i contractor) (date) <br /> C . <br /> ZONING ADMINISTRATOR <br /> J O NT <br /> TOWNSHIP PERMITS MAY BE REQUIRED N r o o m <br /> 0 0 000N <br />