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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. _ <br /> d a <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- <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. o <br /> OW E13Please Prin Contractor or Surveyor or Agent a £ <br /> Add�r�s Address <br /> V <br /> City Stade City,State,Zip Code <br /> MVV zm,0� ) <br /> Telephone Telephone <br /> Emergent /Fire No. and Road Name <br /> //1/ / 7 7_$JA1/U of 6i Q,,;i ' <br /> Legal Description (as indicated on tax statement) o <br /> Permits)Applied for: <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`�• <br /> N <br /> Addition Privy Moving Subdivision $ <br /> v <br /> Structure Use: 0 0 <br /> (family me/cabin, g g4,type of addition, etc.) m <br /> Directions for plot plan drawing: C <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). o <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 (Af <br /> the owner. n <br /> O <br /> 3 <br /> PLOT PLAN _0 m <br /> Z <br /> o c <br /> o. <br /> O N <br /> t O <br /> 7 <br /> A a <br /> �� C) <br /> Q <br /> V N <br /> 0 <br /> N <br /> 0 <br /> y <br /> I" <br /> Z <br /> D <br /> m c c<_ m �cDi nca � <br /> 0 0. o Ra E m <br /> y 'a's 3 <br /> Z N O J m <br /> O O z <br /> m <br /> o co ` 'n <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- 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- Ao 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 /> SIGN HERE <br /> (signal of caner or (date)contractor) E o[ [ o <br /> ZONING ADMINISTRATOR o <br /> TOWNSHIP PERMITS MAY BE REQUIRED ^ o o 0 o rm/1 <br />