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D u 1 Co t�1. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o 5- <br /> TO THE•ZONINd ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m J <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> �il4117-11 <br /> 0 <br /> OWNER (Please Print) Contr ctor or Surveyor or Agent n f <br /> /�i2Gl /d7 J,�N Xee;-#Zgrl�rJ /Z/>�eS S <br /> Ad¢[essAddress , <br /> �e�r✓ PJ�.`i AIAI "5' C t_C _6 S N <br /> City,State,Zip Code City, State,Zi Code ,." <br /> TelQpho9,a Telephone to O <br /> rt f Dl - 75 5/— ;1095` 9/S- 2 �/�F— 37a r <br /> Emergency/Fire No. and, <br /> Road Name 'J <br /> Legal Description (as indicated on tax statement) q <br /> Permit(s)Applied for: o n <br /> New Building _ Sanitary Filling/Grading Camping Unit m <br /> Addition Privy Moving Subdivision o <br /> Structure Use: <br /> (family home/cabin, garage, type of addition, etc.) i <br /> Directions for plot plan drawing: (J <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 OF). 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. X <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by RI <br /> the owner. c <br /> PLOT PLAN 3 <br /> r, - rZ106 � L � LA 3 <br /> 0 r <br /> UJenc <br /> l � n ) fi <br /> 3 �d t4y, Nv O <br /> °n(`1 <br /> (� <br /> "3 c� �j <br /> 9 O <br /> ju as I N C <br /> 3 i ;{7 v � .'.e� x �J C' <br /> Z <br /> r Por*k U.GI beet i U� <br /> 00 an cm <br /> .1 n o< > > - m <br /> C <br /> All - <br /> 0 p' <br /> w O 7 <br /> 2Hnm <br /> O <br /> 4: o: C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: 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- $ 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 n <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. <br /> SIGN HERE CJ• _S�i�B'� O d' ///,,,(((�'''�����I <br /> (si ure of owner oL b (date)_44ding contractor) <br /> ZONING ADMINISTRATOR o' <br /> w 'n <br /> TOWNSHIP PERMITS MAY BE REQUIRED o' n000gm <br /> 0 000 (A <br />