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C� � C ('ly ) j' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> � s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applic Cou Ordma s and the laws and regula- 3 0- <br /> tions of the State of Wisconsin. <br /> N C1 <br /> / N <br /> �Scayj <br /> OWNER (Ple se Print Contr r or Surveyor Ag t _ <br /> _ o <br /> Address Address .. <br /> City, SZip Code City, State,Zip Code t <br /> mac;G <br /> Telephone Telephone <br /> 12 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: 0 < <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m --" <br /> Addition Privy Moving Subdivision o 5� <br /> -7 <br /> Structure Use: 'C4 q s--- Z o <br /> o <br /> (family homelcabin, garage,type of addition, etc.) <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 architectng ed by an architecngjryear, builde�ont ctor,etc.,the p s must be signed and dated by <br /> C <br /> the owner. -• J` ,n h/ (G( LJ N y <br /> 1 a <br /> PLOT PLAN m <br /> Z c <br /> o v <br /> a <br /> p y. <br /> N <br /> S � <br /> o <br /> n_ <br /> O <br /> 0 ^n' <br /> c \ <br /> O <br /> Z <br /> wo <br /> r. <br /> a�0W0aCD a <br /> am <br /> 0 o'< oo oo. <br /> - <br /> a <° dcyo� 3 <br /> n ? W o o <br /> Z <br /> °0 E -I <br /> N: 9 <br /> �: n? O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <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 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 /> bed Fpmises at ar reasonable time for the purpose of inspection. <br /> access to the above d 599 <br /> SIGN HERE <br /> (si n ure o owne or u'ding contrac or) (date) <br /> o: o <br /> o: <br /> ZONING ADMINISTRATOR � }/�� <br /> j/ NNON� NT <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> �00000 0 <br />