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U I CCS{ r1 �. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d _ o <br /> y <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � y �- <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> I A <br /> DAVID W I&yM,9,VN o <br /> OWNER(Please Print) Contractor or Surveyor or A <br /> Address Add-- <br /> 1#,4,g I E <br /> dde1#,4,gIE GRoVE MAI. -5" 369 � <br /> City,State,Zip Code City, State,Zip Code <br /> �'5-7-- 6 7 / 7 } <br /> �/a - N <br /> Telephone Telephone <br /> Emergency/Fire No. a�Q/o5NamCL <br /> ,gI/A/-31, S- &YLI Po. lx.-3 7r OBJ/OD//Wt's AlEST ADO To VoYggF_�7E -1 <br /> Legal Description(as indicated on tax statement) LoT 3l _ <br /> Permit(s)Applied for: L) <br /> 0 <br /> New Building ✓ Sanitary ✓ Filling/Grading Camping Unit m .`.- <br /> r <br /> Addition Privy Moving Subdivision0 ° <br /> v <br /> Structure Use: o 0 ' <br /> (family home/cabin, garage, type of addition,etc.) '_ b <br /> V <br /> Directions for plot plan drawing: N <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN 9 <br /> SFE Sc K FTc <br /> _ AIrAChC o `a <br /> h <br /> n <br /> 0 <br /> O <br /> 0 <br /> J <br /> � r <br /> 0 <br /> N <br /> 0 <br /> N <br /> O <br /> v'/ „ <br /> � <br /> _O <br /> y � � <br /> 4 C = <br /> LD. <br /> 5 dcN003 <br /> 0 0 i <br /> Z i 1 <br /> - m <br /> 7( <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O o n0 IX y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- (iU iF �o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. — : '01 ' C <br /> am i <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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- V <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. to i". <br /> SIGN HERE 0 <br /> 3 : <br /> (sig ure f owner or Ing contractor) (date) <br /> �: i o.mE o <br /> `ZING ADMINISTRATOR S� <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8000 o oS vmi <br />