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vf\, ( one/ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator in m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 6 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett Cour4y Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> // ,.// R 0 P '1 <br /> r -C <br /> OWNER(Please Print) Contractor or Surveyor or Agent n :E <br /> e• � <br /> Address Address _ m <br /> SO .f�'. /�Gr<.l, /yihh �.fO�J �•C�l �c�, �'✓//. S �/�9� _ ) F <br /> City,State,Zip Code City,State,Zip•Code <br /> Telephon �g3Q •.,/e1�S�Lt Telephone r7�nl Nt <br /> Emergency/Fire No.and Road Name <br /> Ria f , v - 21- /3a V/09 ? 37 /CL IA Gov. L <br /> Legal�on (as indicated on tax statement) p <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit o .`.- <br /> r <br /> Addition Privy Moving Subdivision g o <br /> v <br /> Z 'o <br /> Structure Use: l //r P m <br /> (family homelcabin, garage, 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). J r.; <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield(DF). V <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. 11 J <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 lake, C <br /> river or stream, if applicable. X <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by QS' <br /> the owner. 3 m <br /> PLOT PLAN Z v <br /> Mo n <br /> M o <br /> C <br /> fa <br /> J M <br /> co <br /> 8 - <br /> O <br /> O <br /> J <br /> J <br /> O � <br /> w <br /> Z <br /> M >ncm� <br /> m n� � nm aa9 <br /> C w o ; <br /> Z N: Z N o n m <br /> a : : 0 Q <br /> P TN: : <br /> — =2 m <br /> moo: G)0 A <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> a' <br /> So i <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- Mtion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- :i ? go N O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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- 8-P o <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. :' 0^0: <br /> m 3 A <br /> SIGN HERE <br /> (signiru owner orb ' g contractor) (dH e) o <br /> ai i 8i i <br /> ZONING ADMINISTRATOR �_ ' '• <br /> TOWNSHIP PERMITS MAY BE REQUIRED ° N" m <br /> 8 8 888ca <br />