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(_3C) CUrr� <br /> lurnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,�', �T o 0 <br /> ,APPLICATION FOR — LAND USE — PERMITS 3. <br /> o L <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �+ <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 a <br /> tions of the State of Wisconsin. - <br /> N N <br /> N <br /> C <br /> OWNER(Please Print)) Contractor or Surveyor or Agent a O <br /> Address <br /> 7�7V �yT<SY�a//l 6 <br /> Address = <br /> Al <br /> City,State,Zip Code City,State,Zip Code C <br /> Telephone <br /> Telephone <br /> t <br /> Emergency/Fire No.an Road Name - <br /> �l 7� G/HiSV�ZicJ6 �iAi� C <br /> Legal Description (as indicated on tax statement) O <br /> Permit(s)Applied for: <br /> New Building Sanitary >11 Filling/Grading Camping Unit 3 � <br /> Addition <br /> Privy Moving Subdivision o ^°r. <br /> Structure Use: ._�> /7�1' (� of)(u Z <br /> (family ome/cabin, ara e, <br /> g g type of addition, etc.) <br /> ji <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). N 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. r° <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. c7 <br /> O <br /> PLOT PLAN 3 <br /> D <br /> N <br /> Z n <br /> <_ <br /> w m <br /> t � O <br /> O r <br /> �\ N <br /> J <br /> Z <br /> m c 9w m asC m <br /> O c,< M J 0 a-. m <br /> m o.•< n m »n 7C <br /> Zn z N O J m <br /> O N <br /> p J <br /> P : c m <br /> o C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 <br /> S; ' <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- J� : c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 0 <br /> mation I am providing will'be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 de 'bed premises at any reasonable time for the urpose of inspection. <br /> T ' <br /> G n � <br /> SIGN HERE <br /> ign ure of owne ild' ontrac or) (date) <br /> o <br /> ZONING ADMINISTRATOR o o <br /> n -t <br /> M <br /> TOWNSHIP PERMITS MAY BE REQUIRED o j ro <br /> cn u,u,v�oocn <br /> 0000000N <br />