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-nett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (nd o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> -ated.as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> uett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> tions of the State of Wisconsin. /� — t <br /> l41 M N N Imo, <br /> a (�\£ <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> Address Addre <br /> City, Slate,Zifi Code City,State,Zip Code <br /> 3V/_74z;c? 4 <br /> Telephone / Telephone <br /> �SI�S �191)c/ kin 9j s <br /> Emergenq/Fire No.and Road Name <br /> SLegaN (Aj I SE 1 S-meq T- Yo IS- <br /> Legal <br /> l Description (as indicated on tax statement) o <br /> Permit(s)Applied for: 2 •�` <br /> o n <br /> New Building Sanitary X FillinglGrading Camping Unit <br /> Addition ,\Privy Moving Subdivision o 2 ) <br /> Structure Use: �ll� t�A)Pulr16 I •Sanl�c3(J �x1 � 1 0 <br /> (family home/cabin, a of addition, etc.) <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). I <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 /> 3 <br /> PLOT PLAN Z "' m <br /> P v <br /> n <br /> N <br /> O <br /> 7 \ <br /> Jar IV 6 <br /> _ p <br /> N <br /> td f Z <br /> D <br /> � 1 <br /> ll I <br /> YEJ <br /> 7P <br /> I+ OCT 2 <br /> L89 a n4.' 000 <br /> jg' <br /> m <br /> Q✓Ot .nit <br /> O' 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 informa- 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 Xemisea at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> � <br /> SIGN HERE `-S _ �nj\� 1 �\ 1) <br /> (sign re of owner 8r uilding contra tor) (date) o: : o <br /> ZONING ADMINISTRATOR7�-�" <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8888 <br />