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I <br /> Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator CID m 'D o z <br /> APPLICATION FOR — LAND USE — PERMITS J-d 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <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 a <br /> tions of the State of Wisconsin. o <br /> c <br /> OWNEJJ(Please Print) Contractor or Surveyor or Agent o C� <br /> Address <br /> ! �1 <br /> 1 <br /> City,State,Zip Code" City,State,Zip Code <br /> Telephone ---- Telephone 7 <br /> M <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition L,. Moving o <br /> Sanitary Camping Unit 0 ` <br /> 0 <br /> Privy Subdivision 0 <br /> E; ° <br /> Structure Use: I✓—C—c ZF" 1/ IV v <br /> (family homelcabin,garage, addition, etc.) o <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. o <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 CJ <br /> the owner. 6. Provide legal land description. 0 <br /> 0 <br /> PLOT PLAN 3 <br /> a N <br /> N <br /> 0 <br /> i <br /> � c J <br /> l� � --- �y�L .�yc:. /G-G�y O <br /> N <br /> I <br /> n <br /> � st Z <br /> P <br /> Z <br /> l <br /> s <br /> M Wv(na MWr <br /> m a� J-'nm5'. m <br /> d W =� <br /> rli 2 i In <br /> declare that this application (including any accompanying schedule) has been examined by me and to the best of my —" o <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 recognize that n <br /> PP ( 9 Y ) t Ui _ <br /> this information am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a r^ o <br /> 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 m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ` a <br /> person to have access to lPe above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (si n ure of owner Ild ng contractor) (date) <br /> ZONING ADMINISTRATOR <br /> o: o <br /> TOWNSHIP PERMITS MAY BE REQUIREDIn <br /> cn cn�n<noo m <br /> �- ' 000000 <br /> 000000 rA <br /> s <br />