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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ,'o 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- oq <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 n J <br /> tions of the State of Wisconsin. <br /> N d <br /> DCA?J o <br /> OWNER(Please Print) y Contractor or Surveyor or Agent T o �. E <br /> 1195 3;mGc� S/ri0rt .1A Ale - <br /> AAlehrYACC+ v _ <br /> Address Address pQ <br /> ,,-"ArAA) m ;r, n SS/2_3 DAwG1 <br /> City,St e,Zip Code City, State, Zip Co <br /> G/ - '/52 - 5Ry2 7/6 - .OSS- 3257 9 <br /> Telephone Telephone <br /> /7o Ip b // <br /> EmergenGcy ree�Noo. and [load Name <br /> Legal Description (as indicated on lax statement) <br /> Permit(s)Applied for: 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> Addition Privy 9 <br /> Priv Moving h Subdivision o <br /> Structure Use: <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). 0 <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 /> 0 <br /> 3 <br /> PLOT PLAN `0 0 <br /> j=; sh ��alCc o a <br /> O <br /> I <br /> Sem Peer �a <br /> -+T- 130t I N <br /> g u, <br /> o <br /> eel----- N <br /> N : fla� , y� l s <br /> 1jo Close- to 1pl--ll,r.,, � i�pT�K � <br /> NGv!/ Nut" tb InGrc�sn i <br /> �r mM'� 1/�rK `d Y` O <br /> a <br /> Cn T0Waaam <br /> m a m ';a � <br /> a < dC 00 0 Tj <br /> L' `Z N O Mn <br /> O <br /> Zi: :F....:N: m <br /> pi <br /> EF— o LA 0: �r :• : O: o: C <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> PP C 9 Y ) Y Y <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 Ao: m <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this infor- <br /> mation <br /> PP C 9 Y ) 9 <br /> I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 : 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- 00 <br /> "''^ <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 /> m ;N: <br /> N :V' <br /> SIGN HERE ai in <br /> (signa of owner or buildi contractor) (date) o o <br /> b <br /> o:m: :0p <br /> ZONING ADMINISTRATOR <br /> avT <br /> QppPpoo m <br /> TOWNSHIP PERMITS MAY BE REQUIRED �o o o 0 0 0 0 <br />