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K. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o I o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. w m <br /> ,10� SAyc�lsK� SE�� a E (r, <br /> 0 R (Pleas Print) Contractor or Surveyor or Agent v <br /> Add e��W 1 ,LM.; Address <br /> City,State,Zip C de City,State,Zip Code \ <br /> 1 <br /> Telephone Telephone pO <br /> I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> � O <br /> Permit(s) Applied for: 0 °. <br /> m r i <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z c <br /> Accessory Building sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> (family home/cabin,garage,adbition, etc.) 0 <br /> DO <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) � <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 drainfieid (DF). 3 <br /> 3. Show dimensions In feet of thefoliowing:(a) building to all lot lines,(b)building to center line of road,(c)building M z `o <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. if separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. C C� <br /> PLOT PLAN m <br /> V7 <br /> 0 <br /> O Y'] <br /> 0 I}� <br /> Pee, I�Zl rJ <br /> 73 <br /> Sanitary 5cWelrr <br /> (mCm l a 6/4 ray, 10Caf�'cm I c of <br /> al <br /> 6I-ternaf&— EJ-rem , 00 '.0 m <br /> m g m A a <br /> z o 3 on 3 <br /> U ' mei C <br /> 8 ? m A <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <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. 1 , m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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. m 8 <br /> M <br /> m : <br /> SIGN HERE <br /> (signature of owner or DuIdin o or) (date) <br /> v,—C/ <br /> — c ,; <br /> ZONING ADMINISTRATORS <br /> TOWNSHIP PERMITS MAY BE REOUIRED u R o o~d m <br /> 88898888y <br />