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�) ctTITV . <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS d3. <br /> TO THE iONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> a o <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 i of th( State of Wisconsin. - o <br /> / �1/(7Y1 nA f l SIM a o <br /> OW (Please P 'nt) Contractor or Surveyor or Agent <br /> 71-I tin/ aaK <br /> Ad r ss T� Address <br /> ` '. crklP, MA/ <br /> City,State,Zip Co City,State,Zip Code <br /> I <br /> Telephone Telephone <br /> �nn <br /> Emergency/Fire No. and Road Name 1 `J <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for: <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Mov'ng Subdivision o <br /> (familyh�me/cabin, garage, type of addition, etc.) <br /> r <br /> Directions for plot plan drawing: Ji <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings (NS) 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 /> 0 <br /> 3 <br /> PLOT PLAN v <br /> Z <br /> 0 <br /> � � o <br /> 0 <br /> 0 <br /> N � <br /> Z <br /> G <br /> S N N DDOo -0 <br /> m c m o a c rn <br /> 0 c a Dna <br /> a < » m5-3 <br /> 5: mom �. <br /> N 0 <br /> P O <br /> O > : <br /> rn <br /> O <br /> C o) o C <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- A G <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 a <br /> further accept all liability which mayft a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication.I agree to permit county o i ials charged with administering county ordinances or other authorized person to have <br /> access to the above described preMV <br /> es at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> m <br /> SIGN HERE <br /> lure of ower or building co tractor) (date) o o <br /> ZONING ADMINISTRATOR t6,98 <br /> o: o <br /> o: o <br /> � T <br /> NNON �-�N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 0000000 <br /> 0000000lR <br />