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g"Y} =`,-3 n i <br /> Burnett County Office of Zoning Administrator m o 0 <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 v w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 Co <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. o <br /> F, .2/f/��(i96'tE SF Z_ m m <br /> a o <br /> OWNER(Please Print) Contractor or Surveyor or Agent F <br /> _ m <br /> Address Address <br /> GJZ::4ST" wl S , -25`E3�_3 <br /> Cit State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Buildii Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit T <br /> Privy Subdivision o <br /> ,E'G'G � S/fFi'� k � � S3yG " m <br /> Structure Use: c 0 <br /> (family hometcabin,garage, addition,etc.) Z <br /> 0 0 <br /> a <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. <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 /> ZA <br /> 3 <br /> 900 <br /> I ° <br /> o, <br /> Uja <br /> p <br /> N <br /> O <br /> J <br /> o^ r <br /> Ci N <br /> - 0 <br /> O p <br /> IN <br /> I � tql <br /> r <br /> (3 Z I / <br /> i � O <br /> Z <br /> 9 <br /> - ✓ _ <br /> �� m c ❑.mmo ac <br /> Z O : 1 <br /> GA �: m <br /> € c' <br /> O <br /> oi ic ? C <br /> I(we)dedlare that this application(including any accompanying schedule)has been examined by me(usi and to the best of <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are)dssponsible for the — ' ^: ? m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> the <br /> : C <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by he County of Bur- Ivc�1 <br /> Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the 1i i io <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- i 1 <br /> mises at any reasonable time for the purpose of i spection. <br /> m i E ice: <br /> SIGN HERE �00 E E <br /> (sia of owner or ing contractor) (date) <br /> o: a <br /> ZONING ADMINISTRATOR ° : <br /> fT fT(T(TOOK <br /> TOWNSHIP PERMIT MAY BE REQUIRED o00o i <br />