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an �� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m .7, o a <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> w f <br /> TO THE ZONING�ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 62 <br /> located aa shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m = f rp <br /> nett County Land Use Ordinance,Sanitation Co ,and with all other applicable County Ordinances and the laws and regula- 3, n <br /> tions f the State of Wiso <br /> m o <br /> OWN R lease Print) Contractor or Surveyor or Ag t n E <br /> c -F- Ilfb�,� I �1 X13-3 <br /> Address <br /> City,St%te,Zip Code City,State,Zip Code -I <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) O <br /> Permit(s)Applied for. o <br /> New Building Sanitary FillinglGrading Camping Unit m .`.- <br /> r <br /> Addition Privy Moving Subdivision g <br /> Z 'o <br /> Structure Use: P <br /> (family home/cabin,garage,addition,etc.) <br /> Directions for plot plan drawing: J <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). '°r. <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. 1t <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, <br /> 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 byO o <br /> the owner. 3 w <br /> c <br /> PLOT PLAN o <br /> to <br /> I <br /> fl <br /> 0 <br /> I9j <br /> 0 <br /> V <br /> w <br /> 10 <br /> Z <br /> m <br /> -6 Z i d coo 65'r,65'r, <br /> c <br /> S.'-:o1 : 1 <br /> i 9 <br /> _ <br /> S. ' i m <br /> 'a = : S <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 1 am responsible for the detail and accuracy of all informs- ��-i i n: ? m <br /> tion contained in this application(including any accompanying schedule and 1 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. 1 pp 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- $n $ <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 . �c31)~o? <br /> G - � - ?O <br /> SIGN HERE -T $' <br /> (sig u of owner or bu' i contractor) (date) <br /> $i <br /> ZONING ADMINISTRATOR <br /> ONNON���m <br /> TOWNSHIP PERMIT MAY BE REQUIRED m <br />