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n c_a�nl <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d _ o � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <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 applicable County Ordinances and the laws and regula- <br /> tion of the State of Wisconsin. <br /> m = O <br /> OW{�N R(Please Pte' It) Contractor o7 urveyor or Agent o <br /> I.� <br /> Address Adddrrress <br /> �1 rGrulltrY�y. r JLS ST07� l� r�c ¢�C1/�y Zip <br /> State, l.- <br /> Cip,State, ip Code U City,State,Zip Coded rb <br /> 0 <br /> a <br /> Telephone Telephone <br /> J <br /> Emergency/Fire No. and Road Name <br /> r4 It a 64 <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: `» 0 4 <br /> New Building Sanitary _X_ Filling/Grading Camping Unit y <br /> r <br /> AdditionPrivy Moving Subdivision o <br /> Ap ITOW Loo li / <br /> Z <br /> Structure Use: o $ <br /> ( amity home/ abin, garage, type of addition, etc.) <br /> W " <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). r <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. o <br /> 3 V <br /> PLOT PLAN p <br /> Z a F1 <br /> o a <br /> N <br /> Xi <br /> r� � O <br /> J <br /> 0 <br /> j� 1 <br /> Spc�oL Dow'ln�6 Irn <br /> u, <br /> N t <br /> c <br /> J <br /> J <br /> m r <br /> O Iry7R <br /> Z <br /> D <br /> I � I <br /> N a N N A n E <br /> LD. a J »n <br /> aHow ; <br /> N O J <br /> Z Z <br /> OO ; <br /> O N: <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. u <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#3 permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the ab ve described prpmlsr at any reasonable time forl0r&purpose of insp tion. <br /> T <br /> N <br /> SIGN HERE it <br /> (signature of o ner or building contractor (date) <br /> o: o <br /> ZONING ADMINISTRATOR <br /> NON Nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 o o <br /> 0000$ooN <br />