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zc lr(� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator G 0 o o <br /> - APPLICATION FOR — LAND USE — PERMITS d 312 <br /> . o <br /> TO THS 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- 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 of t State of Wisconsin. <br /> / 11— N m <br /> F�/�tl�TiS� A &?e_:;se)AJ S� 1 <br /> OWNER(Please Prri Contractor or Surveyor or Agent a E <br /> A ss Address <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone n ( � -{--//�� I Telephone <br /> Emergency/Fire No. and Road Name <br /> 1,,47:5- ea 7 -/a %�/tel <br /> Legal Description (as indica ed on tax statement) o <br /> Permit(s)Applied for: / 0 L <br /> V o <br /> New Building Sanitary FillinglGrading Camping Unit 0 <br /> r� <br /> Addition Privy Moving Subdivision 0 g <br /> Structure Use: h Z-Y`f /`o o o I <br /> (family homelcabin, 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). <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- n 7 <br /> nary high water mark of lake, river or stream, if applicable. c—{ <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 /> 3 <br /> PLOT PLAN y <br /> Z � Q <br /> �! o a <br /> f N <br /> c <br /> / � w 0) <br /> 0 <br /> 0 <br /> N <br /> l O <br /> J <br /> I� 7 <br /> LA <br /> A <br /> Z <br /> 1 m <br /> �t'�5 ��d0000 m <br /> m <br /> L14X oc ' oyaa3 <br /> _ N[ A <br /> � : m <br /> O: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: 0 `: y <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- c[ m <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- UrY nn G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I U 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 /> p m <br /> SIGN HERE <br /> (sig tyre of owner Ing contractor) (date) o o <br /> o: o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED g o o tmif <br /> 0 0 <br />