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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator a A o 0 <br /> 0 3 £ <br /> APPLICATION FOR — LAND USE — PERMITS <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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. o - <br /> m <br /> T t L t z <br /> DICK i' cam.octP 6l/ <br /> OWNER(Please Print) Contractor or Surveyor or gent o f <br /> A3 S"1acre VOvOcvoUrr_ <br /> Address r V W Address <br /> Lfxv.�fyyY W t J `� S';O �. <br /> City,State,Zip Code City,State,Zip Code I <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name (--" <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: G) I^1 <br /> 0 <br /> New Building Sanitary X__ Filling/Grading Camping Unit <br /> r <br /> Addition Privy tn� Moving Subdivision o <br /> �ClMS cQ Yl-/& gC ''Q'or7aLl q o <br /> Structure Use: o <br /> (family home/cabin, garage, type of additi n,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). <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. Q, <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. c) <br /> 0 <br /> PLOT PLAN 3 m <br /> N <br /> O <br /> / �U N <br /> 1 <br /> C) <br /> V 0 <br /> N 1 <br /> �_- STa�eoWT o•v 9-�9J � �` �— <br /> ro <br /> SMt-d %r T oNw. d K <br /> Lvt� ope,� - /Avoe ft 4� L111 ill <br /> ►7r UK `` aM.000aarn <br /> d8/ n 1• = . 0n-. m <br /> a "!D o M <br /> tt Z w � m O0'0 <br /> N: M <br /> M <br /> N: O : O <br /> S: 0 C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- --o 0 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. o <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 descr' ed premises at any reasonable time for the purpose of inspection. ' �E <br /> T <br /> N <br /> SIGN HERE <br /> (si t re f owner ding contractor) (date) oo , jI <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED no a o0o m <br /> �oo 000fA <br /> d <br />