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Burnett County Office of Zoning Administrator 0 -0 oz <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describ d and m m <br /> located as shown herein.The undersigned egress that all work shall be done in accordance with the requirements oft is Bur. m m <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. » <br /> zytmv~ W. 3-o11 SON w <br /> N � <br /> C <br /> OWNER GRa <br /> (Please Print) Contractor or Surveyor or Agent n O <br /> ao( N 1TE ST• <br /> Address Address m _ <br /> ST PAIL Mtn 5511; � <br /> City,State,Zip Code City,State,Zip Code (gyp <br /> eta , div <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading 1 <br /> Addition / Moving <br /> Sanitary Camping Unit � <br /> Privy Subdivision <br /> o' <br /> N <br /> Structure use: o <br /> (family home/cabin, garage, addition, etc.) Z v <br /> a <br /> C <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o <br /> 2. Show the location of the well (W), septic tank(ST), and drainfield(DF). ^ e <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. ij) N\ r- <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building t lake, V� r <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 da d by <br /> the owner. <br /> DQ0 <br /> LOTLE WooO LAKE P <br /> 35 <br /> VO a <br /> n 4 s <br /> �Y V = <br /> CR6ttJ o1S' <br /> N <br /> 0 0 <br /> WEII <br /> all; <br /> SEPTiC <br /> 1781 THNK 7-13 <br /> ZZ <br /> DRatrJ PZ <br /> ff�d <br /> I aa' <br /> MM 00 00 M <br /> ED. a� =am ';n= <br /> o <br /> wa m': A0n <br /> lI$' o o't 3 m,2 : : 1 <br /> y: <br /> i m <br /> b: C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are) respto the best o �` � ' <br /> m : 77 <br /> oo: :nsible for th <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we p <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County ofBur <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of th <br /> County of Burnett relying on this information I(we)am(are)providing in this application. I(we)agree to permit county oh <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre <br /> mises at any reasonable time for the purpose of inspection. m <br /> SIGN HERE <br /> (sign a wrierorkMildin contractor) (date) <br /> ZONING ADMINISTRATOR /U ' <br /> f.191("Mp0 PM <br /> WNSHIP PERMITS MAY BE REQUIRED o080000vi <br />