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Burnett reunty Office of Zoning Administrator m o Z <br /> ADPLICATION FOR — LAND USE — PERMITS 3 = <br /> TO TIZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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 /> W O <br /> Rurwe ZY Co GaJ Gen <br /> ri o <br /> OWNER Please Print n rl F <br /> ( ) Contractor or Surveyor or Agent o J <br /> f?ou;E-� I� <br /> Address Address tD <br /> City,State,Zip Code City, State,Zip Code <br /> n` T <br /> Telephone Telephone X� <br /> Permit(s)Applied for: ( <br /> New Building Filling/Grading CX1 <br /> Addition Moving o n <br /> Sanitary Camping Unit ct ID' <br /> PrivySubdivision 0 a <br /> N <br /> Sri i a <br /> Structure use: TA RV ONLY 0� <br /> (f mily homeicabin,garage,addition, etc.) o o <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 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 by <br /> the owner. <br /> Provide legaldescription ❑n a side o form) as on ax saemen is o <br /> PLOT PLAN <br /> 3 <br /> / P y <br /> Sem ,,, ✓Z 15�� �Ur �lE ts-A^ d <br /> n <br /> (/ oc o <br /> V w <br /> u <br /> 9J <br /> I <br /> o M <br /> 0 <br /> J <br /> N <br /> J <br /> o. <br /> y � <br /> m <br /> io <br /> 64Z <br /> 0 <br /> I e <br /> JJ (A v(/fir 0 W m <br /> 0 c _goo <br /> O a O m <br /> 0 0 < onaM <br /> T. o. < m <br /> a <ZN_ J 0 <br /> .0 j i to <br /> `Z <br /> fREViGus 4N � <br /> �- y Pam -)-� II5q; Ff <br /> , i--6uea� -jq-W to <br /> �: m <br /> "�I n <br /> o c i C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my � <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all I m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that A ET <br /> : p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (si tur of owner orb it g contractor) (date) <br /> o: o <br /> 'ING ADMINISTRATOR <br /> N N N N T <br /> TOWNSHIP PERMITS MAY BE REQUIRED (Q} v,v, o o u,m <br /> o$ 000N <br />