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J <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> N o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c J <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. <br /> -�I sl rin 2�1r�') S2 <br /> OWNER(Pe / Contractor or Surveyor or Agent <br /> Addres�� ` m I <br /> r-rwl INN 55iD�' Address <br /> J <br /> City, State,Zip Code City,State,Zip Code <br /> Telephone �7G� 7o L/� Telephone <br /> _ \ <br /> Emergency/Fire Id Road Name <br /> Legal Description(as indicated on tax statement) p ` <br /> Permit(s)Applied for: <br /> o \ <br /> New Building SanitaryFilling/Grading Camping Unit .`..- <br /> Addition _ Privy Moving Subdivision 0 o. 3 <br /> Structure Use: - ��fX1w� - �Q�C — �- gr(tcia {�a¢� l y X/O -/�Pc�/0 ' 0 0 <br /> (family home/cabin, garage, t e of addition, etc.) &r 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. <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. cf <br /> // Q, �� gL 0 <br /> PLOT PLAN 61c '1. er-r(r I.& r+ /v�O a13JWV / J z <br /> 0 <br /> 0 1 <br /> At/ <br /> \_ o <br /> V <br /> VN <br /> / 0 <br /> >40n� 3y t� N <br /> I t <br /> i o <br /> I o <br /> \Nt s <br /> I t D <br /> pole- <br /> Setbakr � j IyDa� r <br /> l " <br /> 00 CQ�dd00nS= = oa_ m <br /> < <br /> 4a 0 arcam =aS <br /> P o: : : <br /> P <br /> a : m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E [ 0 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- j : G <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 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. <br /> m <br /> SIGN HERE <br /> (sig ture of owner or building contractor) (date) o o <br /> ZONING ADMINISTRATOR o o <br /> Pn <br /> N N O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED p' <br /> 00000 <br />