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of <br /> umett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 0 0 <br /> APPLICATION FOA — LAND USE — PERMITS 3. <br /> 0 <br /> z y <br /> TO THE ZQNING 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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. o <br /> PAID T c'_Scm �61/n) 6 KE Mcb le, t Af< �< 0 <br /> O E (Pleas riot) Contractor or Surveyor or Agent <br /> lr a <br /> CD <br /> ess Address <br /> "t`p"')an fnas�'?'3 <br /> Cit , st ,Zip C de City, State,Zip Code <br /> Telephone Telephone I <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: `» J <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision o <br /> Structure Use: <br /> (family ho /cabin, garage,type of addition,etc.) a �, <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). 07 u, <br /> 2. Show the location of the well (W), septic tank(ST), and drainfield (DF). U <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. 0 <br /> 3 <br /> PLOT PLAN a � <br /> Z <br /> aC or(� <br /> 0 a <br /> A—R h o(_ <br /> . t <br /> IN i <br /> a <br /> v, <br /> o <br /> J <br /> Z <br /> I � <br /> Perml-c 9o1 <br /> m c nac� m <br /> m a� mangy <br /> y o m m 3 <br /> 9 6 `2 f 1 <br /> �i m <br /> 10 <br /> O: C <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. 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 countyoArcials charged w'th administering county ordinances or other authorized person to have <br /> access to the a ove descried p emi es at an rea able time for the purpose of inspection. <br /> T <br /> SIGN HERE J �? <br /> si re of owner orb 'Iding co tractor) (date) <br /> ZONING ADMINISTRJR <br /> o o <br /> T <br /> ��c M--Mm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o$.o9So in <br />