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�/�1,l.�(-•,�"! �� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d a <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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. <br /> tions of the State of Wisconsin. <br /> Ro!' C2. ( LS-61A/ �O/L�{t �A.vn j�u.-L�Cie-S o. O <br /> m <br /> OWNER(Ffoase Print) � ) /; 7^ Contractor or SuJrvveyor or Agent �^ <br /> Z'ljio fl W/Q.S�iiw4 /r/ /1 S/ � 'I/V�S 9Co� Z-' ✓/'�/HC!' � <br /> Address Address <br /> >f/a2Tl� F /W AJ ssos7 Eftto 5 rte,' ss1Pa d <br /> City,State,Zip City, State,Zip Co <br /> So l-6M ,55_26 - ,P-s S- 3 aS7 0 <br /> Telephone Telephone <br /> .3Pe73 � ; r�ti� ( z 1z <br /> Emergency/Fire No.and Road Name, ' <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: 0 O xn <br /> o <br /> New Building !/ Sanitary Filling/Grading Camping Unit .`.- <br /> r <br /> Addition Privy �(Mo/ving Subdivision g 0 <br /> Structure Use: Q/`FZ4 ///3cr �Y /X '3 / <br /> z o <br /> 0 <br /> (family home/cabin, garage, type of addition, etc.) 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). o <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN `I <br /> 5ACA A AA Z C <br /> pCr <br /> /o6 . 9/ 0 <br /> a <br /> I = <br /> I � a <br /> N L <br /> ,y y <br /> 6DI <br /> / y � <br /> 1 � <br /> e r. <br /> J '6 m C� dm onc ° v <br /> c <; d c 00 o S F. <br /> P = rNiN M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- :Qo m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- : m g G <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. sn: <br /> T N: <br /> SIGN HERE- Z, 'v J —2 d _ F/ <br /> (signature of owner or buildin contractor) (date) 0:3 m No <br /> ZONING ADMINISTRATOR �- 'I;p } <br /> ra T <br /> N N O N 18 m <br /> TOWNSHIP PERMITS MAY BE REQUIRED p,�ook5 m <br /> oog000gf� <br />