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b,A conV . <br /> "ounty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator iv � 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> (HE 'gNING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> ° S <br /> .ocated 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 a <br /> tions of the State of Wisconsin. — <br /> N N <br /> N <br /> OWN P ease Print) Contractor or Surveyor or Agent o <br /> � / M RAIN <br /> Address, ,., v /V'r� L� Address <br /> City, State Zip Code City, State,Zip Code UU <br /> �II 6 <br /> Telephone Telephone <br /> Emergency/ irF a No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: G 0 <br /> 0 <br /> New Building Sanitary FillinglGrading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision o' <br /> Structure Use: o <br /> (family homelcabin, garage,type of addition, etc.) <br /> N ` <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. C <br /> -�,-.1 <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- 7 V <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 a a <br /> a <br /> 0 <br /> vV n <br /> ^) O <br /> 0 <br /> VnVV <br /> C) <br /> N <br /> 0 <br /> N. <br /> 0 <br /> N � <br /> C ' <br /> N � <br /> M c Z.w m 0 a cm m <br /> > > 0 0.-. m <br /> -6 zia - a � �aics <br /> LA. Z 0 0 Q <br /> z o: <br /> P N: y <br /> a€ 'c ; In <br /> 0 : O <br /> 0 c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- oro <br /> Da, T <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <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 ' a <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 /> -n <br /> ID <br /> SIGN HERE <br /> (sign r of owner or bur contractor) (date) <br /> ZONING ADMINISTRATOR <br /> o: o <br /> A T <br /> 14111 <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED Q 01�N oo5P 8cc N <br /> �� 000Nf <br /> 0 <br /> !Y <br />