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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( a o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d 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- 0 m <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. <br /> OWNE (P ease P 'nt) Contractor or Surveyor or Agent o F <br /> Addr s Address <br /> City, 7�� City,State,Zip Code <br /> Telephone S /7/ !7/LCNJI Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m »- <br /> r <br /> Addition Privy Moving Subdivision o 0 <br /> v n <br /> Structure Use: o ° U, <br /> (family home/ in, garage,type4f addition,etc.) <br /> `c <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. c'f <br /> 0 <br /> 3 <br /> PLOT PLAN a rn <br /> Z c <br /> P Q <br /> V' N <br /> N <br /> L <br /> CA) <br /> 1 W <br /> C <br /> '.0 o <br /> n N n, II1V`-�,u1 <br /> O <br /> I <br /> Z <br /> �rS <br /> I <br /> M <br /> c�mm 0amm <br /> c <br /> n1 <br /> A a< - o. m »nom <br /> D G d C y O O <br /> N z O O ro <br /> 0 O <br /> 1 declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> PP ( 9 Y ) Y Y <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- �o m <br /> tion contained in this application(includingan accompanyingschedule 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 :ma <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. �N <br /> � o: <br /> SIGN HERE <br /> (si ure of owner r wilding contractor) <br /> (date) <br /> fl' <br /> ZONING ADMINISTRATOR <br /> _n 3�bSM <br /> Nva oo m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0 oog m <br /> 000 y <br />