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J <br /> Burnett County Office of Zoning Administrator 0 -m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 2. £ <br /> z s <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 Bur- 3 a <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. 0 <br /> 9w <br /> N vC <br /> OWNER(Please Prrint) .r / Contractor or Surveyor or Agent n , F <br /> 11A A. D �Ll lI�C�LLt ti m = <br /> A <br /> Address9-Ph Address �? y <br /> Q 3 0 % /4 J'F_ S C'- <br /> City, State,Zip Code City,State,Zip Code u <br /> 'ti7i <br /> Telephone Telephone <br /> ( r <br /> Permit(s)Applied for: r ?` <br /> J� 4' <br /> New Building Filling/Grading y <br /> Additiont <br /> Moving o �.1 <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> = L.I <br /> N <br /> Structure Use: S l0 n' A,' c ��=� - o <br /> (family home/cabin, garage, addition, etc.) Z <br /> o a v'J <br /> a <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). �, < R <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. F, f' <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, ° r, <br /> river or stream, if applicable. V( ` <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. f \_ <br /> C <br /> 0 c <br /> a <br /> Z JJ <br /> c,0UA// Rd C <br /> v <br /> ca <br /> PRr ✓,4T/ Raicp a <br /> N <br /> ti <br /> yr <br /> G <br /> OAA SToa6G5 <br /> Pr) <br /> o <br /> s/y i,P 70 9r Yon•✓ Dorv✓ �7 30 N <br /> `- <br /> CST,) J <br /> i\ Nru! STeRA <br /> o �— > r s ,•�D /T tl <br /> 70 FT ILIL Z <br /> IL <br /> t31A/ <br /> It. J <br /> Ciul�.T !u 1963 J � 1 <br /> mZ. aOa.m-.m cm m cmO a< Z . 0 <br /> Fn': � y0 =m � <br /> tau/ baa ✓ f �rJ5 <br /> M <br /> D <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that (we)am(are) responsible for the ; m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) [ p <br /> further declare that I(we) recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> County of Burnett relying on this information I(we)am(are)providing in this application. I(we)agree to permit county offi- <br /> cials charged with ad 'nisteri ng county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reason letime for the Pu pose of inspection. �+ <br /> m [ <br /> SIGN HERE <br /> (sigM owner or buil g c r ctor) ` Pi <br /> ` o <br /> (date) �`: E 0; ; <br /> ZONING ADMINISTRATOR d <br /> IJ N O IV N m <br /> !,m <br /> 0000 o <br /> WNSHIP PERMITS MAY BE QUIRED o000 5U) <br />