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f, <br /> Burnett County 7410 Co. Rd. K, 41102, Siren, WI 54872 Office of Zoning Administrator m -0o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 5-7 <br /> located as shown herein.The undersigned agrees that all work shalt be done in accordance with the requirements of the Bur- '1 c - <br /> nett County Land Use Ordinance,Sa ation Code,and with all oth r a lica County Or�nces and the laws and regula- 3 ii <br /> tions of the State of Wisconsin. 9y o[t .: <br /> 1,2 <br /> OWN (PI a Print) �' A CoRtRqioor <br /> japor Agent n <br /> Address 'l Addres II)IlL7s AF <br /> , <br /> City,State,Zip Code TT City,State, V � <br /> MIN zap-ate -�so� b <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o 1� <br /> Sanitary Camping Unit 0 <br /> 0 <br /> Privy Subdivision <br /> Structure Use: -19 "Y � M1S <br /> (family home abi gara a additi etc.) 0 00 t" <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. 6. Provide legal land description. <br /> --� <br /> PLOT PLAN L�� N <br /> Z T <br /> %% l/ o n <br /> r <br /> CJ C N <br /> _ � V <br /> 3 ` <br /> �-3 <br /> Cn <br /> Fk- <br /> LJ�'�, <br /> 1 q <br /> I <br /> N <br /> Z <br /> O <br /> Z <br /> lei ? <br /> G1 <br /> 0a• Don—.m <br /> 01 SO <br /> m <br /> 0 <br /> 1 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 <br /> PP (including Yaccompanying 1 g A <br /> information contained in this application includin an schedule and I further declare that I recognize that o : O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> 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 l u, <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above.described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (sig of owner or ing contractor) (date) <br /> ZONING ADMINISTRATOR — <br /> // m <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O J m <br /> Ut(TNO�00 <br /> 0 0 0 0 0 0 m <br /> 00000 ', Co <br /> Q'h.SiN�c/1 SK <br />