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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and o, <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- <br /> tions of the State of Wisconsin. o l <br /> /l/C' 1� f'Q % ��0�'C%� /l Fr LONST.ELICy/OBJ m 1 <br /> O NER(Please Pri9,t)) Contractor or Surveyor or Agent n f <br /> � � Address � I <br /> ki / 5'� _3a <br /> City,State,Zip Code City,State, Zip Code <br /> Telephone Telephone (> <br /> Emergency/Fire No. and Road Name �. <br /> 20 (09's /77 <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit N »- <br /> Addition �Privy Moving Y n Subdivision / 0 ,0r, <br /> Structure Use: �•�-n��Ll�/YIE 6� �S�LS7V� �CGI� 0 0 <br /> (family home/cabin, garagethype of addition, etc.) <br /> r ` <br /> Directions for plot plan drawing: / <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NS) and indicate North (N). <br /> 2.Show the location of the well (W), septic tank(ST),and drainfield(DF). o <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 /> 0 <br /> 3 <br /> PLOT PLAN P <br /> Z ` <br /> O D <br /> 0 <br /> e � t f(jr z <br /> s <br /> W <br /> O <br /> N <br /> O <br /> 3 r <br /> 0 <br /> Z <br /> 1 <br /> C <br /> NC M.N N O a Cm m <br /> o a< 000n-. m <br /> a < cyo= 3 <br /> rn •� � o �m <br /> Z o <br /> m <br /> ID <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- p o :c» : y <br /> ryA: <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- : o: 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. I <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. im'e <br /> m o: <br /> SIGN HERE <br /> (sig atu a of owner ilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> J N O J <br /> TOWNSHIP PERMITS MAY BE REQUIRED u, m <br /> 0 0 0 0 0 N <br />