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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator d A 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 Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n - �- <br /> tions of the State of Wisconsin. " p <br /> N � <br /> JTEFHeNso�✓, <br /> OWNER(Please Print) Contractor or Surveyor or Agent f <br /> L,4%re AO,I4 <br /> Address Address t n <br /> DA uryo <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone fl• <br /> r <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o R <br /> Sanitary Camping Unit o <br /> Privy Subdivision .<.- <br /> m r <br /> k <br /> o � <br /> Structure use: <br /> (family home/cabin, garage, addition,etc.) o v° <br /> m <br /> Directions for plot plan drawing: J <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 /> O <br /> PLOT PLAN 3 N <br /> SEe h; Iyfct/�o Sof o <br /> N <br /> O <br /> J <br /> uu1�1'. <br /> N <br /> t <br /> k./, <br /> e <br /> N <br /> N <br /> O_ <br /> O <br /> J <br /> O <br /> 0 <br /> O <br /> T <br /> N /'-� <br /> O CJ <br /> Z <br /> a <br /> 0 r D D O <br /> p c mnacm <br /> n- <br /> LD. <br /> N O O <br /> 0 O r ,z [ 1 <br /> O N: ' M <br /> czO <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 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 have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (si ature of owne or building contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> i en-1 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0' <br /> o �bbbo f <br />