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or) C-arm' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n M o a <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and rn <br /> located'as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c C <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n J <br /> tions 9fAhe State of Wiscongin. <br /> OWNE �r,�eas Pr'nt) Contractor or Surveyor or Agent n <br /> Add ess Address m <br /> Z22U/ mom/ 2Z7,-) <br /> City, t te,Zi Coe City, State,Zip Code <br /> Tele one Telephone <br /> i�h ,Pik <br /> Emerge F/yc erin . aA d Road Name <br /> Legal Description (as indicated on tax statement) <br /> o <br /> Permit(s)Applied for: � o <br /> New Building Sanitary Filling/Grading Camping Unit 0 4 <br /> Additionm <br /> Privy Moving Subdivision <br /> 0 <br /> v <br /> Structure Use: 0 0 <br /> (fa ily home/cabgarage, addition,etc.) I <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). J r <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield(DF). 1-' 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 lake, 0 <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 n <br /> the owner. O o <br /> 3 <br /> PLOT PLAN v m <br /> Z c <br /> P <br /> a <br /> m <br /> CIC1 <br /> m <br /> Cn <br /> R <br /> � d <br /> o� <br /> a o <br /> m <br /> O ti <br /> N <br /> C <br /> Z <br /> m c�mmrDi nc�� <br /> coo <br /> a fSAC <br /> d <br /> i i m <br /> = <br /> € =2€ m <br /> »i D <br /> (/A g c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <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- m <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- o o. <br /> _$ <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. E i O^o <br /> m d N <br /> m Nl ` 3 �xj <br /> a N. <br /> SIGN HERE <br /> (sign f owneror it g contractor) (date) <br /> c i <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PER TS MAY BE REQUIRED oc o$m <br /> D o o$gfm/l <br />