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?7 Chi)' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 0 <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 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. y m <br /> w � <br /> 13Atan weidendoAU n o <br /> f <br /> OVffRease P int Contractor or Surveyor or Agent o <br /> 1' 60 205 <br /> Ales. MN 55051 Address <br /> M r , '1 <br /> City, State, Zip Code City,State,Zip Code Q <br /> (612) 679-5218 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Lot 3. CSM Vol. 13, Pa. 154, Sec. 24. T41N, R17W. Town ob Sw<a&s <br /> Legal Description (as Indicated on tax statement) <br /> e <br /> n O <br /> Permit(s) Applied for: 0 °. <br /> w r <br /> DwellingAddition Filling/Grading Camping Unit o <br /> —X— v <br /> Z o <br /> Accessory Building SanitaryPrivy Subdivision P m <br /> Garage <br /> � r <br /> Structure Use. SanitaAy On V ilcj;7G 1PGff-11 r <br /> (family home/cabin, garage,addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M r <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 (OF). 3 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 0 Z a <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C <br /> PLOT PLAN m ri,,, <br /> L � <br /> N <br /> m <br /> n <br /> 0 <br /> SEE ATTACHED o <br /> O y <br /> Z <br /> o N V ? Dnp m <br /> F m <br /> Z <br /> D <br /> � � tD <br /> gm i i a <br /> i <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 accuracy of all informs- w m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I L$ o g <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- ;,1 H <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 3yU� o <br /> access to the above described premises at any reasonable time for the purpose of inspection. y� $ ro <br /> m y ^ n <br /> ro w <br /> SIGN HERE <br /> Wade Ru�,shotrn 9/30/92 8 <br /> a . <br /> (signature of own o 'uil in contr ( ste) a, <br /> ZONING ADMINISTRATOR Z <br /> TOW HIP PERMITS MAY BE REQUIRED Qu — 1 1992 -5tH . too o"S 'Mn <br /> 888 8 $88ai <br /> _moi <br />