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Burnett County Office of Zoning Administrator ; M £ o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <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- 3 n <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. <br /> m m <br /> OWNER(Please Print Contractor or S n /t F <br /> G[;�,�e )7u, l`I� LAVATION <br /> Address Address NCR 59, BOX `? <br /> -e-y' 5 �d- L.,'t Sett Zoe PdL SMner, WI 54801 <br /> City,State,Zip Code City,State,Zip Code (715)635-7482 (A <br /> Telep one Telephone <br /> Permit(s)Applied for: ( M <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary __ Camping Unit V <br /> 0 <br /> Privy Subdivision 0 <br /> Dn <br /> Structure Use: <br /> v <br /> (family home/cabin, barage, addiY n,etc.) o 0 <br /> a <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). 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. C�Uj o <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, Gn ,1 <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 /> o <br /> 3 r <br /> 0 0 <br /> Z � •• <br /> o <br /> u, <br /> 7 <br /> Q <br /> -f= N <br /> O <br /> N <br /> 0 0 <br /> 0 <br /> m <br /> a <br /> Z <br /> 0 <br /> z <br /> �o <br /> M Nvfnr DD 03-0 <br /> m a`c ''- 30ani <br /> m <br /> o c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to thebest of m <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are) responsible for the i i i E m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <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 the <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 coun ordinances or other authorized person to have access to the above described pre- ' `N <br /> mises at any ason le time for th rpose of inspection. ' p <br /> � <br /> SIGN HERE 7 <br /> i nsrGre of wner or uIng co act ) (d te) <br /> ZONING ADMINISTRATORm <br /> r^T <br /> TOWNSHIP PERMITS MAY BE REQUIRED �08 888N <br /> l <br />