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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o� o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. H m <br /> c <br /> Chad Pedeneon a <br /> OWNER (Please Print Contractor or Surveyor or Agent o <br /> 14138 Bloom >�oad <br /> m <br /> Address Address <br /> Gnant.6bung, WI 54840 �- <br /> City, State, Zip Code City,State,Zip Code <br /> (715) 463-5797 <br /> Telephone Telephone I <br /> 14138 Voom Road (9 ) <br /> Emergency/Fire No. and Road Name <br /> PaAcet NW 1/4, SW 1/4, Section 22, T39N, R19W, Town ofi Weht MaA/shtand, <br /> Legal Description (as Indicated on tax statement) Bwtnett County. Lp <br /> n /n <br /> Permit(s) Applied for: o` <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary �— Privy 0 Subdivision <br /> Garage o0 r <br /> Structure Use: SanitaAtf On y <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <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). a3 n <br /> 3. Show dimensions infeetofthefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building Z Q <br /> measurement to the ordinary high water mark of lake,stream, or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n• <br /> dated by the owner. m M <br /> PLOT PLAN m <br /> 1 <br /> n <br /> 0 <br /> SEE ATTACHED 4X' <br /> o � <br /> f/1 <br /> Z <br /> f <br /> D oc � m sr+ � aF <br /> "am i M <br /> v < Z H o �' 3 <br /> o E OM T� <br /> m <br /> /ri up i; caO <br /> �1 : <br /> 8 i M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracyof all informa- .n m a <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. I i 8 m 8 <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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have n a o <br /> access to the above described premises at any reasonable time for the purpose of inspection. ,m 8 0 <br /> T ' 3 n <br /> e m <br /> SIGN HERE <br /> Wade RuA4hoom 10/8/92 <br /> (signature of owner o in ntra (date <br /> ZONING ADMINISTRATOR <br /> TOWNSHI PERMITS MAY BE REOUIRED CT ' 9 199 �a rn ru o o m <br /> 888 8888N <br />