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y , <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -00 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 Q 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ord' nces and the laws and 3 0. <br /> regulations of the State of Wisconsin. y ° d <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> zG 5'_12 .TT, <br /> Address Address <br /> .Sr R 4c N W i'S 5Y172- <br /> City, State, Zip Code City, State,Zip Code Q� <br /> L519—'17 3 3 l� <br /> Telephone Telephone ry <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) 10 <br /> � -" <br /> Permit(s)Applied for: o Ic <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit 0 °^ <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage tructure Use: - Dec,✓ r- <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M C <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). 3 <br /> 3. Show the location of any lake or flowage- If within 1000 ft. and the location of any river or stream- if within P <br /> 300 ft. an n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. m <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. m <br /> PLOT PLAN 24& <br /> d <br /> �3) m <br /> t <br /> r I � ? <br /> L o � <br /> ae T� <br /> •-well <br /> ti <br /> 360 <br /> m <br /> 00 M ]o <br /> Z mo Z.z : 1 <br /> ✓ P <br /> I Wo <br /> N ig € o <br /> m C <br /> 8 ' n <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informa- <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 8 m 8 <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 ` <br /> 3 8 0 <br /> m 3 A o E <br /> SIGN HERE <br /> (signature of own Ing contractor) (date) <br /> O ; <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 8 $ 8 $ 8rmn <br />