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Burnett County 74111 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( m a { 1 I o <br /> APPLICATION FOR - LAND USE - PERMITS 3 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 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 d <br /> N � <br /> Stephen Bnown a f <br /> OWNER (Please Print) Contractor or Surveyor or Agent v <br /> 28271 South RiveA Road <br /> Addr$anbuAy, wI 54830 Address <br /> City, State,Zip Code <br /> 656-3168 City, State,Zip Code <br /> Telephone Telephone <br /> 28271 South RtveA Road �t <br /> Emergency/Fire No. and Road Name <br /> pct. SE 1/4 NW 1/4 Section 20, T40N, R11w, Town oU Union <br /> Legal Description (as indicated on tax statement) 9 <br /> Permit(s) Applied for: o 0 <br /> 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision o <br /> Garage } J <br /> Structure Use: SanitwtU On2U <br /> (family home/cabin, garage,addition, etc.) it <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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). C 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 z <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 <br /> dated by the owner. bi ; IfTltl <br /> C i <br /> PLOT PLAN fA <br /> > C <br /> C <br /> I � <br /> 0 <br /> + o` <br /> N <br /> SEE ATTACHED. <br /> m <br /> o � <br /> N <br /> G <br /> Z <br /> s <br /> I \ <br /> f <br /> < H' Z goo 0. r0 3 <br /> f m a <br /> m c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- -C. a tD I m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- w m ;3 O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m ut <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 4�' g m 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, y, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g <br /> m 3 n <br /> SIGN HERE wade Rubbhotm 6124192 , <br /> r^ a <br /> (signature of owner or building contractor) (date) p o s <br /> ZONING ADMINISTRATOR /L- <br /> M NNM m <br /> TOWNSHIP PERMITS MAY 4E REQUIRED N v, , o o 8 m <br /> $ <br /> 888ai <br />