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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w 1 a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> u o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Q 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 the State of WEs ns i n. <br /> VM S LLQ/NE � O <br /> OWNER(Please Print)/� Y� Contractor or Surveyor or Agent o. <br /> o� oZ�/� � w<J <br /> Address Address 1D <br /> GYANTS�u rC, L✓ l , SYd �� <br /> City,State,Zip Code City,State,Zip Code <br /> Tele hone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) p <br /> Permit(s)Applied for: 0 o <br /> New Building Sanitary Filling/Grading Camping Unit 0 'C.. <br /> w � <br /> Addition Privy Moving Subdivision o a <br /> A <br /> I <br /> Structure Use: P a <br /> m <br /> (family home/cabin, garage,addition,etc.) � <br /> Directions for plat plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). o <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 lake, C <br /> river or stream, if applicable. M <br /> 5. If,separate plans are su mi a by an architect,engineer,builder,contractor,a c., ned and dated by 0 <br /> 0 <br /> the owner. 0 <br /> ,I 9 (n <br /> PLOT PLAN Z c <br /> P n <br /> N <br /> C !-> <br /> m9� z_- = <br /> 90 <br /> 0 (D <br /> 8 � <br /> �,e 0 R <br /> m <br /> l� <br /> G <br /> s p <br /> 4' <br /> t <br /> YU2-�1 I N <br /> c�m Sio nc�� <br /> SOU m <br /> n� m an <br /> m '---na <br /> v < ^' cw6'F3 <br /> w Z m <br /> 030 — <br /> oZ o: Z ; - <br /> E mrnE S <br /> «€ a'q m <br /> g: nom : C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- , m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. E O <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- <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. m m»v:' <br /> � E 3 <br /> : vv <br /> SIGN HERE ' ' <br /> (sig u of owner b Idin contractor) (date) c: <br /> o: <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> RIS 88 8 8$gfn <br />