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on �'owp <br /> Burnett County Office of Zoning Administrator ; M s o <br /> APPLICATION FOR - LAND USE - PERMITS 3t <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 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- <br /> tions of the State of Wisconsin. �, m <br /> Gary Marion Donald Daniels = o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o. F <br /> 3501 67th St_ E_ Pn Rnx 316 m <br /> Address Address <br /> Tnvpr (;rnvp Heights , MN 55076 Siregr 11��5AR72 w <br /> City,State,Zip Code City,State,Zip Code .z <br /> 612-457-4037 715-349-5533 <br /> Telephone Telephone 3 <br /> a <br /> Permit(s)Applied for. '- <br /> 0 <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> N <br /> Structure Use: ° <br /> ro <br /> (family home/cabin,garage,addition,etc.) Z <br /> P ° <br /> (`' m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). i!' o <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield (DF). ,: <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, <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 /> 0 <br /> o - <br /> 'a - o_ <br /> Z <br /> O o <br /> O <br /> s <br /> SEE ATTACHED STATE APPROVED PLAN ND z <br /> r✓ C <br /> rj g <br /> N <br /> _I O <br /> 1— O � <br /> I <br /> No <br /> 0 <br /> O a W <br /> N <br /> m n <br /> O p <br /> N � <br /> Co <br /> W <br /> T co <br /> W <br /> Z <br /> O <br /> Z <br /> Ul D <br /> O <br /> V <br /> m (n V Nr D D my <br /> m n'� -nm na>, <br /> mE � mo6ro3 <br /> Z o f m•2 : 1 <br /> n2€ m <br /> 8i [ c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> i <br /> my(our) knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the ' W <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of theof <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- ;o i <br /> mises at any reasonable time for the purpose of inspection. m E <br /> SIGN HERE ""'- - ' " "--- qo <br /> o <br /> (sig of owner or bijiLaWfig contractor) (date) <br /> ZONING ADMINISTRATOR �� � ��` <br /> w-n <br /> mA <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0 000f <br />