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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 M o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> iu o <br /> Z y <br /> TO THE'ZONING ADMWISTRAfOR: 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 Bur- m `m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of theStateof Tonsin. - <br /> OWER(Please ri Contractor or Surveyor or Agent o J <br /> lu 01 <br /> Address Address <br /> City, tate Zip Code City, State,Zip Code <br /> �oI - ��cl , (gtlC ds� <br /> Telephone j Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied fo> Gt <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> Addition Privy Moving Subdivision o <br /> Structure Use: <br /> (family home/cabin, garage,type of addition, etc.) 7L <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). 0 <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 ordi- <br /> nary high water mark of lake, 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. o <br /> 3 <br /> PLOT PLAN Z m <br /> a <br /> o' <br /> J <br /> Z <br /> OaLW <br /> I <br /> 0 <br /> 0 <br /> N __4 <br /> i <br /> � Z <br /> I D <br /> C <br /> � fnv(nr DD� <br /> m a� 3'nm nn <br /> O G d C N O J <br /> m : 'Z N O J <br /> Z O 1 <br /> XIRI m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- ` i o i m <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 a <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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (signature of owner or b lding contractor) date) o o <br /> ZONING ADMINISTRATOR ��� 666 $ <br /> a NNON �+N <br /> TOWNSHIP PERMITS MAY BE REQUIRED 60 :9 n <br /> 00000 <br /> 0000 oo <br />