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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator ( o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <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- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. <br /> tions of the State of Wisconsin. o <br /> V /GI fl.Yn.-4f / \ D /l2/t W�ll/J –11 � ''� /Il�� �,.���GC[/1 <br /> a <br /> OWNER(Please Print) Conr r Surveyor or Agent o m <br /> 309 o sr s.,�.t� /, t- A� � 3i 3� ����i � t� /2�� <br /> Address Address <br /> ,0,,, k,,qy pe tiia., <br /> City,State,Zip Itocle City,State,Zip Gbcle C` <br /> l S"Z 1f 75— D <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building „— Filling/Grading <br /> Addition Moving v ,� <br /> Sanitary Camping Unit o <br /> o ^. <br /> Privy Subdivision <br /> Structure Use: <br /> T4 1At a <br /> � (family homelcabin,garage, addition, etc.) o 0 <br /> a <br /> 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. 0 <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. I , <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 o _ <br /> PLOT PLAN <br /> o N <br /> Civ t - Z <br /> o n� <br /> IL/o, <br /> , t <br /> <wi. �. <br /> I S'0 f �� 14►y2 0 <br /> WE LL — 7 — T <br /> 3�tr" <br /> 1-7 <br /> Z <br /> v <br /> m c�mmoa <br /> oon <br /> m a� - amn <br /> N ? O O <br /> � O Z <br /> M <br /> O <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o c C <br /> PP ( 9 Y ) Y ll <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I reco nize that n O <br /> PP f 9 Y ) 9 E a : <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing w <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE�ti"-^— �" _ t 7� <br /> ( Wn ure of ownej,,or building contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> "'TOW PERMITS MAY BE REQUIRED o 0 0 0 0 o T <br /> NNO U 00 <br />