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of1corte( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator N a o <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 c� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> t' ns of the State of Wisco n. <br /> 1P C01 X - <br /> N � <br /> C <br /> N 0 <br /> NER lease Printh 1 —� Contractor or Surveyor or Agent o f <br /> d <br /> A cess Address <br /> City, State,Zip Coe City,State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> 'm ) <br /> Permit(s)Applied for <br /> O <br /> New Building Sanitary Filling/Grading Camping Unit H <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> Structure Use: SAA)'I <br /> (family ho a/cabin, garage, type of addition, 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. <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. o <br /> 3 <br /> PLOT PLAN z <br /> 0 0 <br /> n <br /> 0 <br /> 0 <br /> o <br /> 0 <br /> I <br /> Z <br /> 7] <br /> I <br /> 0 c oN+ n a cm m <br /> 0 U � � a-. m <br /> LD. a - m a 30 <br /> <[ ao= 3 <br /> N O rp <br /> O > : <br /> N: i m <br /> 2 ! m <br /> A <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ' n 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 n <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 /> m <br /> SIGN HERE , 7' <br /> (si r t owne or building contra or) (date) o: o <br /> ZONING ADMINISTRATOR <br /> fn -n <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />