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( I <br /> Burnett Salo Co. Rd. K, #102, Siren, tll 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z rn L <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- 3 n C/I }j <br /> tions of the State of Wisconsin. E <br /> N d <br /> I )Ah L\ �reVl n LA <br /> /' O <br /> f <br /> OWNER Ple a Print) p i- Contractor or Surveyor or Agent <br /> Addre�� Address `4 <br /> VNp (� z <br /> City,State,Zip Code City,State,Zip Code <br /> �3- _;11 L/ <br /> Telephone Telephone <br /> c A <br /> Permit(s)Applied for. <br /> New Building X Filling/Grading . <br /> Addition Moving 1 0 <br /> Sanitary X Camping Unit 1 �_ <br /> Privy y Subdivision o <br /> t o <br /> ��Q <br /> Structure Use: Mid1_t_3>`�f�t��p,I v <br /> (family"1lomelcabin,garage,addition,etc.) 0 <br /> 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. CIO J1 0 <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 lake, <br /> river or stream, if applicable. y.1 � <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. 6. Provide legal land description. <br /> �0 <br /> PLOT PLAN 3 I c `G�r T) w <br /> Oa a <br /> I.i�t y t.RfdE _ <br /> N In <br /> Lel Z <br /> a fn <br /> m <br /> n� <br /> `tD m <br /> 0 <br /> N <br /> O <br /> o <br /> 4,;N <br /> V Qr n <br /> fye 38' --3 <br /> 7LSl 1x7$1 <br /> Z <br /> AAf K. <br /> t <br /> d <br /> ,A Z o ,2 <br /> o ' 2i <br /> (ruk i.RKI: € C) <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> j= A i i m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing -� <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> \ A <br /> SIGN HERE c"` tih (OW dirVtl <br /> igpature of ownerorb (ding contractor) (date) i <br /> yam) o: ; o <br /> ZONING ADMINISTRATOR �_JnFn ') <br /> 'TOWNSHIP PERMITS MAY BE REQUIRED NNS O N <br /> 00000� <br />