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anty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <br /> y <br /> ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and c <br /> :d as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> .ins of the State of Wisconsin. m w <br /> / S�l y <br /> a a O <br /> m <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> Address Address <br /> _ C � <br /> S0ST 0/ / /f- SS '7S 6, Z <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> S �0"1 d <br /> Emergency/Fire No. and Road ame <br /> Legal Description (as indicated on tax statement) o `h <br /> Permit(s)Applied for: AGPlje A7,, 7o t, Aa .e <br /> A-4, v -f5ho/" o o <br /> n <br /> 0 k1 6y SM r, oi' Wis.> <br /> New Building Sanitary r, Filling/Grading Camping Unit J <br /> r <br /> Addition <br /> Privy <br /> Moving Subdivision o <br /> Structure Use: Z <br /> (family homelcahip, 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(NS)and indicate North(N). C r <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). 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. r <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. 3� J <br /> PLOT PLAN a L G, m <br /> Sfha/r > JJ <vf5 FIAv yAAI — 0 a <br /> l N <br /> I O <br /> J n <br /> C <br /> 0 � 9 <br /> J <br /> y <br /> ' I `0 0 <br /> see- AITaj ,pc � ti <br /> N n <br /> J Ilu <br /> Uav�ce� 337 mor AcGr�f�l°.,. � � <br /> 4 <br /> SAAt p 1`1399 <br /> errw�+ � I <br /> 1 Z <br /> mcM.mm0amm <br /> cMm maa� =aa <br /> LA. <br /> .Z �' pJfO 3 <br /> O <br /> m <br /> O <br /> 1 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 informa- 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 /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> 7 <br /> SIGN HERE 4a++uru <br /> g ture of o r or building contractor) (date) <br /> o; <br /> o: <br /> o: <br /> ZONING ADMINISTRATOR <br /> T <br /> v �N� o m <br /> TOWNSHIP PERMITS MAY BE REQUIRED ogoo o N <br />