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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3, o y <br /> N <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M m '� .G <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. m m J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. <br /> o v O <br /> / l t QS 1..� �Y � C <br /> l <br /> 6 <br /> OWNER(Please Print Contractor or Surveyor or Agent f <br /> 7 '1 e IY�-ITS L4FfP �✓ o J <br /> Address ° O <br /> Address <br /> �� cxa rstirh IA)ISc N <br /> City,State,Zip Code City, State,Zip Code O �n <br /> Cl D <br /> Telehone Telephone <br /> Emergency/Fire No. and Road Name <br /> " '2_ 6, rr� � Dirty-e_ 2 <br /> n o <br /> Legal Description (as indicated on tax statement) — <br /> Permit(s)Applied for: n o <br /> New Building Sanitary Filling/Grading Camping ° ~- <br /> Sanita Fillin /Gradin Cam in Unit 0 <br /> r <br /> Addition / 'Privy MovingSubdivision <br /> (moo � <br /> Structure Use: o o d Sh P d �l xC G' \') �56 �( o ° <br /> (family home/cabin, garage, 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). <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. o <br /> 3 <br /> PLOT PLAN a u, <br /> Z c <br /> " n <br /> 0 <br /> iso+ <br /> C' <br /> `vQA,f�r-IEL9 � <br /> ( a � o <br /> n A <br /> 3D �✓ajt <br /> La�2 <br /> �S1 <br /> -- ~ <br /> 0 0'< J ° 0 a <br /> m a� - am ^;ate <br /> N <br /> ~ m <br /> o: <br /> Oo p C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o : J : y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- I 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. 1 : a : [ <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 des ribed premises at any reasonable time for the purpose of inspection. <br /> T <br /> ry <br /> SIGN HEREJOA <br /> in <br /> (si n ure of own r building contractor) (dat ) o ; $ <br /> ZONING ADMINISTRATOR <br /> � <br /> GN N O N m <br /> � TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 0000 Dorn <br />