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on gr�ff) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,q M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <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- J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. N <br /> — i I� <br /> ^ V 1 <br /> MnrK Soft G� rt �k uMary e� y <br /> _ <br /> o <br /> OWNER Please P 'nt) -9 Contractor or Surveyor or Agent n (D F <br /> 5(05`2 Tfx 5 bre S o . <br /> j <br /> A dress Address oQ <br /> City, tS ate,Zlp CodeCity, State,Zip Code <br /> ga <br /> oi�� 5 - 5911 � � <br /> Telephone �ag 7 „Telephone Loa(o IrC � Slr�rrl p� r� 1ti2' � <br /> Eml_erg7ylFire No.and Road Name <br /> n+ 5 C V t1 f' l7F <br /> Legal Description (as indicated on tax statement) (0 <br /> Permit(s)Applied for: L) <br /> 0 <br /> New Building X Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy M0vinVg ' Subdivision o o <br /> Structure Use: \a� a L/ f`a g <br /> 0 o <br /> 0 0 <br /> �- (family hom4idabin, 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 /> 3 <br /> PLOT PLAN a m <br /> Z = <br /> CJ ee /Q7raGned ° <br /> survey 0 <br /> � \ 3 <br /> o <br /> \ N <br /> 49C \ <br /> . Xp ^DO \ \ o ..._ <br /> 00 <br /> f o � <br /> y0 <br /> V Z <br /> loo' B ~ 9 <br /> s«,.a PE, <br /> well <br /> Zoo <br /> ' m cM.mm 0acmm <br /> c _ <br /> Z 0 A <br /> � I/YlP/bS�dUIS a�'x�c� <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 informa- i/) : 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. 1 �mn <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 /> T N: <br /> A <br /> m <br /> SIGN HERE ( G� 1lY1 /3��J � m in <br /> (yigM1zfih o o er or buildin tractor) - (date) <br /> b : n <br /> ZONING ADMINISTRATOR gn F <br /> 0 IJNON ���PA <br /> Pm <br /> N(T(T(11OOm <br /> T NSHIP PERMITS MAY BE REQUIRED O o 0 0 0 0 0 f/1 <br />