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(3f\ c o M O- <br /> Burnett Count 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator cn m -V0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE Z04ING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located asshown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m d) <br /> nett Cou.ty Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions o!the Slate of Wisconsin. " p <br /> 67 <br /> OWNER(Please Print) Contractor or Surveyor or Agent n F <br /> Add- Address <br /> City,State,Zip Code City, State,Zip Code <br /> l,/ 2 — 4.17 <br /> Telephone I- ' <br /> Telephone <br /> 309ff/ 161 W(e 014U 5 Oerp <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition /Privy Moving Subdivision <br /> Structure Use: iF .(Z/�"' d = ►at xa-�a I 'Qcy D r o 0 <br /> (family home/ca in�i g rage, type 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). 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. n <br /> 0 <br /> PLOT PLAN 3 <br /> C r.9.9 ----�1f J a � — o <br /> Bio' r H. <br /> 0 <br /> �: <br /> . e <br /> 1INJ <br /> o <br /> 3 <br /> J <br /> 0 <br /> S <br /> TSVZ � I Jz <br /> It 'l v N <br /> cAA1 Wf a 300 <br /> queecP [a' IN � <br /> Ta Peo.L 0-1- ��• 9 ' <br /> M ()-0(1fr DDm y <br /> Q<> = 8a`- m <br /> O m =am ;Za M <br /> t✓ N�tnwYa °c <br /> q1... O J�O <br /> rte. �^4,• Z <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O o E :n_ : '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- "Ao 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. Imn <br /> further accept all liability which may be a result of the Count of B t rel in on this information I am rovidin <br /> P Y Y Y Y' 9 p gin this ap- :w:E <br /> plication. I agree top my officials charged with adW0f9renqgx.dunty ordinances or other authorized person to have <br /> access to the ab escribe remises at any reason <br /> _11,raii4enhe purpose of inspection. <br /> T >u: <br /> m UUP'\lI' <br /> SIGN HERE <br /> (si at a of owner o b ildi con or) (date) 4F <br /> oL0: :mo <br /> ZONING ADMINISTRATOR o:m' r'o <br /> ro <br /> vi :v v� u m <br /> TOWNSHIP PERMITS MAY BE REQUIRED i J N O V m <br /> U(TNITOOpI <br /> O O O O 0 i <br /> o0oo$o4iN <br />