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ri u?oC—GR CC5,nP <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS z o s <br /> TO TH@rZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein.Tt*undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> m <br /> nett County Land Usp Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> fyli � <br /> fe._Je_ AI f:ArQ C <br /> m O <br /> OWNER(Please Print) Contractp{or Surve or or A- <br /> gent ' a f <br /> Cat- 5�1 � Y ISIS { .0 d <br /> A <br /> Addr s Address. <br /> City,State,Zip Code City, State,2ip Code II ' <br /> Telephone Telephone �J � <br /> I <br /> Emergency/Fire No. and Road Nam <br /> � 3/S � #. <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: `~ <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy 7� Moving Subdivision o <br /> Structure Use: ����" —� a° <br /> family home/cabin, garage,type of addition,etc.) 1 z <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). C m <br /> 2.Show the location of the well (W),septic tank(ST), and drainfield (DF). r^ I V <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. O <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. o <br /> 3 <br /> PLOT PLAN P <br /> 0 0 <br /> J o <br /> J <br /> W <br /> s <br /> C' <br /> (J N <br /> i m <br /> �f <br /> p o <br /> f� <br /> or <br /> N �' 1 <br /> VX <br /> � S <br /> M to v CO r- DD C3 'D <br /> M c .mw 0 a a M <br /> 0 a< J J o a- <br /> m <br /> a <° dcyo� 3 <br /> o :o: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o I n aE <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- o` 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. I :0a <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 remises at an reasonable time for the purpose of inspection. <br /> P Y P P P � �E <br /> m EOE N; <br /> m:o: <br /> SIGN HERE3:ovEy <br /> fi b: T <br /> (sig ur f owner pyr�w.ilding contractor) (date) 0:0; SDn o <br /> ZONING ADMINISTRATOR <br /> ytm <br /> TOWNSHIP PERMITS MAY BE REQUIRED ao8 go fA <br />