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Cf-\ c orY� <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z 5 �( <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- mc <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. o <br /> Al 0 <br /> OWNER(Please Print) / Contractor or Surveyor or Agent - <br /> ��� <br /> Address Address <br /> City,Ztate,Zip City, State,Zip CodeI <br /> Telephone Telephone �- <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary '� Camping Unit n ct <br /> Privy Subdivision 0 <br /> m r <br /> r� <br /> Structure Use: fO�4z OK � <br /> (farrAly home/ca in, garage,addition,etc.) o a° <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). Kl <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, J <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. <br /> 5. Provide ega description on the side of thisform) as on tax s a emen Oo <br /> PLOT PLAN 3 <br /> o m <br /> Z Q <br /> o a <br /> cq o <br /> 1 <br /> n <br /> C <br /> N <br /> o <br /> J <br /> .yr <br /> T <br /> � N <br /> N Z <br /> 0 <br /> z <br /> ( V D <br /> I <br /> m c mmn aca-0 <br /> m n - O "nZ <br /> 9 C <br /> d C mO J 3 <br /> M H O J n <br /> N <br /> m <br /> hn: O <br /> Og 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 <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that p <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 <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE O <br /> (si r of owner uilding contractor) (date) <br /> ZONING ADMINISTRATOR o o <br /> i i i i i w T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N m <br /> 00oo 000fmA <br />