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O11. (7Jt� A V < <br /> Burnett county 7470 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> '— 3 <br /> APPLICATION FOR — LAND USE — PERMITS d <br /> o <br /> TO THt ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m J <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 n .� <br /> tions of the State of Wisconsin. <br /> o <br /> OWNERfi(PleaPrint) Contractor or Surveyor or Agent F <br /> o = <br /> C2 r. se v <br /> Addr sf - Address f '� <br /> City,State,Zip Code City,State,Zip Code t✓ �\' S' <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: G7 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit n <br /> r N <br /> Addition Privy Moving Subdivision o <br /> WF <br /> Z <br /> Structure Use: 91, (� <br /> (family home/cabin, garage, type of addition, etc.) I <br /> m <br /> Directions for plot plan drawing: <J F <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. o <br /> 3 -0 <br /> PLOT PLAN o rn <br /> c <br /> o Q <br /> n <br /> F O <br /> i <br /> U <br /> N <br /> ri <br /> N <br /> n �p <br /> 0 C <br /> S O <br /> Z n <br /> O VAS` <br /> 0 <br /> 6 ' <br /> e� N <br /> O I � <br /> y qqq <br /> rYl <br /> Z <br /> t f � <br /> y <br /> c <br /> G <br /> M p)vmr' >>W 'p <br /> m <br /> y � Ho �53 <br /> o: =0 P <br /> LA 1 :a <br /> S o: i_o :ce C <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- In <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation <br /> nfor 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- <br /> plication. I agre to permit county officials charged with administering county ordinances or other authorized person to have ov <br /> access to the ove described remises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (sig r of owner or ding contractor) T (date) o ? " <br /> ZONING ADMINISTRATOR <br /> T <br /> NN O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED u v v n o o gem <br /> ggggggo u) <br />