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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C0 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3. ' <br /> _ o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 171 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- Co <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions oftheState of Wisconsin. - O <br /> KJ �rVC2� w w <br /> c <br /> OWNER(Please Print) Contractor or Surveyor or Agentrb <br /> n �O <br /> 1173 Sr So . <br /> w <br /> Address Address In <br /> OeI449 GrOvK W", 5_V_0 I <br /> City,State,Zilf Code City,State,Zip Code <br /> /' I v �F so <br /> Telephone !V !~ or Telephone <br /> Emergency/Fire No. and Road Name <br /> T-3 1 -7W 'Da#1teN n <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: a <br /> New Building Sanitary _X_ Filling/Grading Camping Unit 3 <br /> Addition Privy Moving 0 <br /> Subdivision o <br /> cl <br /> Z <br /> Structure Use: —) � 9 v <br /> amily home/cabin, garage,type of addition,etc.) — m <br /> Directions for plot plan drawing: 'I <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). O <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. i <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 pp�� <br /> the owner. o y <br /> 3 1 <br /> PLOT PLAN z <br /> o v <br /> a <br /> J� r1L�� 2OL 0''�" <br /> l <br /> ' l <br /> I ^ N <br /> o <br /> O O <br /> N ff <br /> Z <br /> a <br /> 0 N DDE_ m <br /> m <br /> S � 0aas <br /> w <br /> a N' o M 0 3 <br /> Z o� :Z ; i <br /> N: m <br /> m <br /> n O <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' m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation gw <br /> ; E <br /> 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 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 thea ve described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE Al, <br /> (sl atu a of owner iding contractor) (date) " w' <br /> ZONING ADMINISTRATOR _ <br /> iJ ON ��N nl <br /> TOWNSHIP PERMITS MAY BE REQUIRED n oov <br /> $ S Sog <br />