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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,N o o <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <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- <br /> tions of the State of Wisconsin. 9 <br /> m m <br /> m V <br /> O <br /> OWN (Please Print) Contractor or Surveyor or Agent <br /> ��ZTSS <br /> Address <br /> X�' Address <br /> City, State,Zip Code City, State, Zip Code <br /> 612_ 'CIA : -l-T '0 oc, <br /> Telephone Telephone <br /> �4 - ,�t IFX"F7 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: M o <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving � Subdivision o ° <br /> (� v <br /> Structure Use: �= i� — -� 4lexi a& <br /> O a <br /> (family ho elcabin, g age, type of addition, eta) 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. <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. a <br /> 3 <br /> PLOT PLAN c N <br /> Z c <br /> o Q <br /> n <br /> / <br /> 0 <br /> J <br /> N <br /> 1 � <br /> 0 <br /> O �_w <br /> J m_ <br /> a <br /> O <br /> Z <br /> \1 � <br /> r <br /> M c 1 N N 0 a c M <br /> �J�l/V 11/lK/[/7 / �/"r "i•� � T. OJ� 3 <br /> ��laa o z <br /> M <br /> m <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- 'o 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 o icials charged with administering county ordinances or other authorized person to have <br /> access to the above described pr se y reas le time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (si of o//w��ner or ildi�/g contractor) <br /> ZONING ADMINISTRATOR <br /> T <br /> N N O N N M <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> $000000 (A <br />