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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator� 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 <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. p <br /> N d <br /> /c/✓A/LO 6g.m C.,5 V/,' f' �. D- fJlJ/L 'xi <br /> OWNER(Please Print) Contractor or Surveyor or Agent a f <br /> ///JSG' /r i n 4+ 577- f1 L <br /> Address Address <br /> r�oN .IeP�Cs in/v Sry33 L2if�3flF� <<•t Sy,.F9.3 <br /> City,State,Zip Code City, State,Zip Code <br /> 45�_i.2 - 7SS- 65-0/s <br /> Telephone Telephone <br /> /-/.0 F "" e;'?g Y e�' C'l e- <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> m <br /> Permit(s)Applied for: 0 <br /> 0 <br /> New Building lk Sanitary Filling/Grading Camping Unit — .`�- <br /> W <br /> Addition Privy Moving Subdivision o <br /> Structure Use: de_.All 10 A'6/5 __�WK oZ o 8 <br /> 0 <br /> (family home/cabin, garage,type of addition, etc.) m <br /> r <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 /> O <br /> PLOT PLAN 3 <br /> N <br /> Z c <br /> 0 0- <br /> n <br /> 5 <br /> N <br /> 0 <br /> f <br /> U1 <br /> 0 <br /> J <br /> @ <br /> o <br /> L) <br /> n Z <br /> V <br /> o � <br /> 1 <br /> M (n vmr DD coy <br /> M c .d m 0 n c <br /> rn <br /> m n< J- nm as <br /> N N O J m <br /> N <br /> A <br /> In <br /> 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 y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- = $ E 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 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 <br /> ,7 m <br /> SIGN HEREAk�7/4 - Sy�GT iF" <br /> (sig`n�a�u�re_Of owne�.r r building contractgr) (date) E o E [ o <br /> ZONING ADMINISTRATOR �jJ <br /> NNON � <br /> TOWNSHIP PERMITS MAY BE REQUIRED �Mp�pNMm�' m <br /> 00000 CA <br />