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%;ounty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d 0 <br /> HE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> ated as shown herein.The undersigned agrees th II work shall be done in accordance with the requirements of the Bur- m <br /> att County Land Use Ordinance.Sanitation Code,and ith all other applicable County Ordinances and the laws and regula- 3 n R <br /> tions of the State of Wisconsi o J <br /> 116x+5 �IOUP/ y d <br /> OWNER�7O <br /> (Plleease Prin Contractor or S rveyor or Agent <br /> I� o r� £\ 2, JV Y. 1 4 w m <br /> m <br /> Address WER� J �,{.^� Address _ <br /> �W( Ly t <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Ni�►I L�I��..gK��D - � <br /> 330 m <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary X Filling/Grading Camping Unit 3 <br /> r <br /> Addition Privy Moving Subdivision g 0 <br /> v <br /> Structure Use: o o <br /> (family homelcabin, garage, type of addition,etc.) z <br /> Directions for plot plan drawing: <br /> f � <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North (N). 3 <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. v <br /> 4.Show dimensions in feet of the following:(a) i (b)building to center line of road,(c)building to ordi- <br /> nary high water mark of lake, river or stream, i 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 /> 3 l! <br /> PLOT PLAN P <br /> N <br /> Z `c <br /> n <br /> ED <br /> 0 <br /> a <br /> > <br /> Q <br /> U , C>ollo <br /> o U <br /> A <br /> O <br /> O <br /> 0 <br /> O <br /> n S <br /> Z <br /> I 9 <br /> IvY <br /> 0 c� oyi oacc m <br /> _. <br /> 0 a 0 0 a <br /> T.T ate - m =am <br /> <' m mop 3 <br /> w 0 �m <br /> Z <br /> M <br /> �o 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 <br /> nowl- <br /> ed a and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracyof all informa- ` Ao m <br /> tion contained in this application(including an accompanyingschedule 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. I � n <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- <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. <br /> T <br /> N <br /> fA <br /> SIGN HERE <br /> (signature <br /> "o�f owner or building, ntractor) (date) <br /> ZONING ADMINISTRATOR .L►1.lGd f cot�t'N11 (J�' <br /> N O N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 o m <br /> �000 000y <br />