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1' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator CI� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> w ' <br /> 0 <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- <br /> tions of the State of Wisconsin. - O <br /> Ronald, , nes y <br /> OWN R (Please Print) Contractor or Surveyor or Agent f <br /> AdM Address <br /> City,State,Zip Code City, State,Zip Code \ <br /> Telephone Telephone <br /> i <br /> Emergency/Fire No. and Road Name c <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`. <br /> Addition Privy ` Moving Subdivision o 0 <br /> IT1�fz�lLl� <br /> Structure Use: o a <br /> family home/c bin, garage,type of addition,etc.) <br /> Directions for plot plan drawing: (X <br /> 1.Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North (N). 1 l� <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). V 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. n <br /> o <br /> 3 <br /> PLOT PLAN <br /> N <br /> Z <br /> 0o 0 <br /> O <br /> I Ila <br /> cp <br /> U1 <br /> i N <br /> O <br /> 0 <br /> \ N <br /> O <br /> 0 <br /> O <br /> N I4� <br /> r I <br /> Z <br /> C <br /> rn <br /> mc� dr�ncmrn <br /> ate ,' ° <br /> m 0a <br /> <: d wow 3 <br /> N O J O <br /> Z <br /> O ] : <br /> �: M <br /> Q <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- _ 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- o m <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this infor- � o C <br /> PP ( 9 Y ) 9 <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. <br /> T <br /> N <br /> di <br /> SIGN HERE <br /> (silLn lure of owner(p�{bu�J�ding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> (_ `J 1 I"f I UI o j o <br /> Q NNf NT <br /> TOWNSHIP PERMITS MAY BE REQUIRED " m <br /> 00 0000 <br /> 00 0000ln <br />