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Office of Zoning Administrator d 'a o 0 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 �. 3 <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> application for a Per <br /> for the work described and w <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes app' m <br /> all n <br /> nett shown here <br /> Land Use in.The Ordinance,Sanitation ned Code,anees td wiith all other bapplicable County Ordinances lanth the d the laws anfd hegula- o J <br /> N w <br /> tions of the State of Wisconsin. " <? <br /> (�iz z e r c�2 <br /> f'T l- e `� n f <br /> OWNER(Please Print) Contractor or Surveyor or Agent o m <br /> �N w <br /> Address ( <br /> As ylf w ( SKs� 1 <br /> �— City,State,Zip Code I <br /> City,State,Zip Code <br /> G 2 0 3 4 Telephone <br /> Telephone <br /> 7- u94tl ` N a <br /> Emergency/Fire No.and Road Name •h <br /> G <br /> Legal Description(as indicated on tax statement) 0 o .(.. <br /> Permit(s)Applied for: ° \r <br /> Camping Unit <br /> Sanitary Filling/Grading s w <br /> New Building Subdivision 8 <br /> Privy Moving <br /> Addition . Z <br /> G� e w <br /> Structure Use: g addition,etc.) <br /> (family homelcabin, garage, J <br /> Directions for plot plan drawing: <br /> dor. <br /> 1. Show the location and size of all existing buildingsand daa nfielnew ld(DF). <br /> (N B)and indicate North(N. <br /> 2. Show the location of the well (W) septic tank(ST), 0 <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. l <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. 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated y o v3 c <br /> the owner. Z n <br /> PLOT PLAN <br /> m � o <br /> �pD) 1 m 0l <br /> a� ' °<) <br /> it— <br /> LJ <br /> 0 <br /> 17 ' G <br /> ° T <br /> t d <br /> 3z Z <br /> r� a <br /> 0' I' <br /> 1 � <br /> 7 <br /> 100 <br /> m cM0W0aaarn <br /> c%yTe a { I? <br /> ^2Aµ Lr, c = N z �o0m ; <br /> Z o, ?� ; 1 <br /> Pi P „N i m <br /> CA <br /> 'n [ fJ <br /> W SQQ M�fS ��' ' o <br /> K <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c o : gH O <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy h all informs- a N m <br /> tion contained in this application(Including any accompanying schedule)and I further declare that I recognize that this infor- o $ <br /> fmation I am beurther accept all Iliiability lwhichelied may be a result of upon by the Che Count of Burnounty of Burnett ett ely n1g on thisarmining informat on Iwheam providing in th slap- oa <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 /> V. <br /> (date) <br /> n ture f ow e r building contractor <br /> SIGN HERE ) $ <br /> ZONING ADMINISTRATOR $ 0 0 0� <br /> TOWNSHIP P RMITS MAY BE REQUIREDo o S o o S 0 <br />