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ONr-� (- r" 'Yj <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS . <br /> TO THE _3NING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c V� <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 Wisconsin. <br /> N � <br /> OER(PI as / Contractor or Surveyor or Agent `} F <br /> Lel / wP6t'TP,✓' 7A/(GQ�,/ <br /> 27/_3 5olny-21 -T <br /> Address I Address <br /> L 2,6GYPR y a// ON'pw <br /> City, State,Zip Code City,State,Zip Code <br /> $66--L/4/6z _746--4.3,$"- 7e /V�Z <br /> Telephone Telephone �? <br /> ff*�: F,iv 6 Zp y 1WVZz?P rC,nl'6.9 V /iso <br /> Emergency/Fire No. and Road Name <br /> PGL 40,1512S.01,70n LOT SM NP61 /6ov 4o'fS-) <br /> Legal Description(as indicated on tax statement) T o <br /> 'm <br /> Permit(s)Applied for: 0 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition � Privy Moving Subdivision <br /> ( o <br /> Structure Use: .) �a— / t e> o a <br /> (family home/cabin, garage, type of addition,etc.) I <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). o <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 /> 0 <br /> PLOT PLAN a m <br /> �— -- o a <br /> ROCIT <br /> 11g67 <br /> a <br /> o <br /> J <br /> N <br /> O <br /> Z <br /> / VLyl } <br /> (,r.Jt U N 8• <br /> N./IcrGsf !I <br /> 76 ba <br /> /6' <br /> 00 C700mv(nr DDOn ommm <br /> m 0. — o-m x3' 70 <br /> v o 5; °' 0 m o'=' 3 <br /> E Q� N : `2 N U J(0 <br /> Z o � .z <br /> J <br /> o f 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- c : m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 /> T ' <br /> m i i <br /> m <br /> SIGN HER T <br /> (se <br /> owne b ding contractor) (date) <br /> V: N <br /> ZONING ADMINISTRATOR o o <br /> T <br /> N N O N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED v v u n o 0 0 m <br /> 0000000M <br />