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0 fV C oM If ' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. – v <br /> N d <br /> �sF6< OCG /D13C ���crNS `i2UCTi � n. <br /> OWNER(Please.Print) Contractor or Surveyor or Agent °- F <br /> .� HU T)i <br /> Address Address `D <br /> (LJr�s 7rfL _?/� Er1J LlJ ; 3Z!`7 Z <br /> City,State,Zip Code City, State,Zip Code 1 <br /> Gu / P >3 C' S-� �/- 2-J <br /> Telephone _ Telephone <br /> J'�, lo - 7SGJ <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> m <br /> Permit(s)Applied for: ° <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> 4i <br /> Addition Privy Moving Subdivision g <br /> Dery 10'e(IL <br /> Structure use: Z <br /> (family home/cabin, garage,type of addition, etc.) o m <br /> Directions for plot plan drawing: <br /> 1.Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North(N). <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 ordi- <br /> nary high water mark of lake, 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. 0 <br /> 1� 0 <br /> PLOT PLAN 0 R <br /> Z c <br /> —� p n <br /> 5 N <br /> y <br /> � 1 J <br /> C e <br /> M L 1 Vj <br /> I C�� f1! � UyOGr J <br /> Q N t'O 51ki0e 512 Q L � (n <br /> — --- — 0 <br /> N <br /> m o <br /> v; � <br /> E X00 o <br /> DM\ 1V-- � , a <br /> r <br /> �dLPWmi"T <br /> J <br /> f tz � I11 mvmr D y <br /> MO v7.0 n In <br /> 7 5A✓v0 <br /> 1 L3 ff ✓ r> ji 1pc.k raP een o 1 ° 0 T. <br /> m. 7io <br /> _� TOC pChi 2 : m <br /> ,0 O <br /> Oo c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of o <br /> my knowl- o: J I y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- oA m <br /> tion contained in this application(including any accompanying schedule)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. 1 17 <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this a - <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 /> SIGN HERE mL <br /> (at ure of owner or ding contractor) (date) o ? o <br /> ZONING ADMINISTRATOR <br /> VNO V N m <br /> TOWNSHIP P MITS MAY BE REQUIRED m <br /> 0000 ° N <br />