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Bumett County Office of Zoning Administrato o M f o <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v w <1 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- Om `m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regulal--3- n �- <br /> tions of the State of Wisconsin. 7,M Jt m <br /> w <br /> K <br /> OWNER(Please Print) Contractor or Sr n <br /> SEPTIC �t0MAVATION m <br /> etTN I�o(LTEr �EYI unn 59, <br /> e_ ��wu Rm <br /> Address Address CC,�,,,,..^.e 9,B x 478 i= <br /> 1615 3rd Ave- nvj Spm <br /> City,State,Zip Code City,State,Zip Code(7115)MME <br /> VditGh�vr Mn 55112 <br /> Telephone Telephone �� Z <br /> Permit(s)Applied for. y �� <br /> New Building Filling/Grading v� <br /> Addition Moving o O <br /> 1 <br /> Sanitary Camping Unit -{ <br /> Privy Subdivision <br /> w <br /> Structure Use: o <br /> v <br /> (family home/cabin,garage,addition,etc.) o <br /> 0 <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. �-� 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, <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 /> 0 <br /> 3 <br /> v o <br /> Z <br /> 0 <br /> 1- CA t,^ <br /> o- <br /> n <br /> 1 w <br /> 3 m <br /> / J <br /> �3_l <br /> O <br /> J <br /> jp 0 <br /> 1 <br /> T <br /> N <br /> Z <br /> 0 <br /> Z <br /> a <br /> J <br /> oe <br /> O � <br /> m c9oNim>>to <br /> 0 a< JJon-'m <br /> m nuc 'nm ';n� <br /> ` m C <br /> w <br /> 00 J m <br /> m <br /> N' <br /> M <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of m m E —y <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) jO <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 i i i <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- ` P <br /> mises at any reasonable time for the purpose of inspection. <br /> Qd _ � <br /> SIGN HERE <br /> (signature of owner or bui ontrac r) !. i(fie) <br /> ZONING ADMINISTRATOR I r N— N m <br /> 6666 <br /> TOWNSHIP ITS MAY BE REQUIRED ) 0000N <br /> E <br />