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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator o Z <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 Z y <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- <br /> tions of the State of Wisconsin. 3 <br /> JA <br /> fo - 7,11C O <br /> OWNER(Please Print) Cont r for or Surveyor or Ag✓sF}t\ <br /> ,'� T lv d <br /> Adc! $ Address <br /> / r d <br /> City,State,2ip Code' _ _ City,State,Zip Code <br /> 2!z 3 _ Q <br /> Telephone P Telephone � <br /> Permit(s)Applied for: (� i <br /> New Building X Filling/Grading <br /> Additionr` <br /> Moving g o <br /> Sanitary X Camping Unit O <br /> Privy Subdivision o 0 <br /> Structure Use: T?1;:r f / '� ^m F� ! ^7 r r <br /> family home/cabin, garage, addition, etc.) o o° <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 lake, <br /> river or stream, if applicable. in <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. 6. Provide legal land description <br /> n <br /> PLOT PLAN o <br /> 3 <br /> P N <br /> Z ` <br /> Q <br /> CD <br /> o a <br /> � y <br /> I <br /> l� <br /> j f rn <br /> :J <br /> Z <br /> (� <br /> ' rD <br /> dCO <br /> l i'/✓' L m c _ N1N 0 c � <br /> 'Inm <br /> 8 <br /> Z p rp <br /> Lotoe� e-jv fi7 $C lctp�G o : Z <br /> N. <br /> m <br /> o i c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all In <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that i i p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a io <br /> permit. I further accept all liability which may be a result of the County of Burnett relying on this information I am providing c, <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized i <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE '^ <br /> (sign re f o er or ding contractor) (date) <br /> o <br /> ZONING ADMINISTRATOR oo o <br /> OWNSHIP PERMITS MAY BE REQUIRED O 01 Mm <br /> /o 0 0 od G m <br /> oocCA <br />