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Burnett County 7410-Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m c a <br /> APPLICATION FOR — LAND USE — PERMITS 3- <br /> 0 <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- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions Stateof Wis onsi�� p ,& 2 <br /> -r y o <br /> w V <br /> OWN (Pls�se Pint) „n Contractor or Surveyor or Agent a f <br /> m � <br /> Address Address <br /> e <br /> City,State,Zip Code City,State,Zip Code <br /> � 4i <br /> Telephone Telephone ry <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: G) <br /> New Building Sanitary Filling/Grading Camping Unit 6 <br /> w <br /> Addition Privy Moving Subdivision Sor„ <br /> Z <br /> v <br /> Structure Use: WP a <br /> (fa 'y hometcabin, rage,addition,etc.) 7L <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). CQ <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, C <br /> river or stream, if applicable. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 n <br /> the owner. o <br /> �I a y <br /> PLOT PLAN7I z c <br /> � P n <br /> H � <br /> m <br /> I� <br /> { <br /> I <br /> m <br /> o <br /> a <br /> m <br /> ro <br /> o <br /> r I <br /> Z <br /> 31 <br /> G <br /> cDi acmes <br /> v' °croo-3 <br /> N � wp �r0 � <br /> Z O <br /> O i <br /> zii i a* i m <br /> C) <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- g` ' ii C ' C <br /> PP C 9 Y ) Y Y MI <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- ; m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- v : o N G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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. E [ ! O^o <br /> m N <br /> SIGN HERE <br /> V O; <br /> (signature ner or buil contractor) (date) !� o <br /> ZONING ADMINISTRATOR <br /> n <br /> NSHIP PERMITS MAY BE REQUIRED $' N 8 8 o m <br />