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,j, i - i •l Y I V <br /> BurnetFCounty Office of Zoning Administrator 00 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <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- <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 o <br /> Nt 7", n n O <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> I t c 70 0 <br /> Address _ Address <br /> 4� (Jl -1 <br /> City,State,Zip Code City,State,Zip Code -Z <br /> i 6t, 7ti2_ i 1 <br /> Telephone Telephone <br /> Permit(s)Applied for: t� <br /> New Building Filling/Grading n <br /> Addition Moving <br /> Sanitary Camping Unit o <br /> Privy Subdivision 0 <br /> IUP�(� �(l)Elli nG� d �afl (l, g <br /> Structure Use: �J <br /> (family homelcabin,ga(age,addition, etc.) o <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 take 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. <br /> 6. r1ovide Tegal description on the side ot thISform) as on ax s a emen o <br /> PLOT PLAN 3 N$ <br /> Z Q <br /> AIIACNC=a T. <br /> T. <br /> So <br /> IN <br /> �y893 r' <br /> J <br /> m <br /> Z <br /> 0 <br /> 7 Z <br /> �� D <br /> rQ_\ <br /> m a� m a <br /> O G y <br /> N <br /> Z O <br /> O O <br /> M <br /> P: j C : C) <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my `.o <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 /> PP (including Yaccompanying ) recognize n <br /> information contained in this application includin an schedule and I further declare that I that <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 m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE ✓ / <br /> (s' natur of owner or ing contractor) (date) <br /> o; o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N m <br /> 0000000u) <br />