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611- I-I aW. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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- m c <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 Wiscon <br /> (�AVtie � - -si�arilas <br /> leas rint <br /> ) Contractor or Surveyor or Agent n Q f <br /> OWNER <br /> sy Oto P.J. Ig- Z <br /> Addre Address � <br /> City, State,Zip Code City,State,Zip Code :P <br /> Telephone Telephone <br /> Emergency/Fire No.�d RoaCd NOa6 <br /> me � <br /> n <br /> C.!%�J &)j � 6 <br /> Legal Description (as indicated on tax statement) p A <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition �J Privy /� Moving /Subdivision O <br /> Structure Use: F'GjN ✓'`�=� ` � �c�JS�U j o so o <br /> 0 <br /> (family homeicabin, g age,type of addition, etc.) m <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). <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. n <br /> 0 <br /> PLOT PLAN a <br /> 0 n <br /> See <br /> a <br /> I <br /> iv, <br /> C' <br /> � ca <br /> r0 <br /> 0 <br /> c I <br /> 0 <br /> y � <br /> ( Z <br /> Mco-0rnrD W <br /> 0 c �.mmn c <br /> n Q< > > n — <br /> m a r »n m <br /> .5 <br /> m <br /> Z O Z : <br /> � <br /> i N i [ W <br /> WN0 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Ci o: y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- J'-E $ E In <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 /> SIGN HERE , y jQ_ I4 <br /> ( ' tura of 6 or building contractor) / (date) <br /> o <br /> ZONING ADMINISTRATOR . S€ o <br /> L N NON m <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 000000 N <br />