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r'�t d <br /> Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator d - 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> ,v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m _. <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0 <br /> L� <br /> tions of the State of Wisconsin. <br /> OTE (PleasQ Print) Contractor or Surveyor or Agent <br /> 1tSl ^� <br /> Address Address 1' <br /> City,State,Zip Code City,State,Zip Code 1_ <br /> G <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building --416— Filling/Grading <br /> Addition Moving o 7— <br /> Sanitary <br /> Sanitary Camping Unit n o <br /> Privy Subdivision 0 �- <br /> �' r <br /> Structure Use: <br /> (family home/cabin, garage,addition,etc.) 0 a <br /> a <br /> m <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). <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 lake, <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 dated by <br /> the owner. 6. Provide legal land description. <br /> PLOT PLAN 3 <br /> v <br /> Z Q <br /> o a <br /> r y <br /> 1 <br /> w <br /> i <br /> r. <br /> 0 <br /> �S ,v o <br /> IN <br /> t,� prt <br /> W <br /> �7 Z <br /> o Z <br /> l L CI <br /> 16n <br /> l� v t 3 � 1 m c�Nwn <br /> n <br /> m - n <br /> o''o <br /> N <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my � <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all F J o i m m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that A : p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a ' o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing ' <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to h access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> sign of owner_Wguilding contractor) (date) <br /> o: o <br /> ZONING ADMINISTRATOR �` ` <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 00000 o <br /> 00000 0 <br />