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Burnett County 7418 Co. Rd. K, #102, siren, 111 54872 Office of Zoning Administrator W0 0 <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 <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- 3 a <br /> tions of the State of Wisconsin. — 0 <br /> N d <br /> N O~ <br /> ' C <br /> OWNER(Pie a Print) - Contractor or Surveyor or Agent <br /> Address Address v <br /> Dw,14rY W, . S Y r---r c, <br /> City,State,Zi 0 Code City,State,Zip Code \ <br /> /430� Ysc, 4J <br /> Telephone Telephone <br /> Permit(s)Applied for: 1� i <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary _ Camping Unit o <br /> Privy � ^ Subdivision om' <br /> cN o <br /> s <br /> Structure Use: <br /> (familq homelcabin,garage,addition,etc.) o <br /> a <br /> m <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 /> 171 0 <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 byv <br /> the owner. 6. Provide legal land description. n G <br /> 0 <br /> PLOT PLAN <br /> 9 (A <br /> Z � c <br /> o a <br /> N <br /> I J <br /> c� <br /> C 0 <br /> y = <br /> N <br /> O IIS <br /> J <br /> J <br /> V t O <br /> .O. <br /> T <br /> 76 o cv <br /> D N N D D W-0 <br /> 0 a c m <br /> 0 a< Da- <br /> m n� N any <br /> a <E 0F,9 <br /> N O J� <br /> W <br /> OZ O `z � <br /> J N: <br /> m <br /> o f i i c i C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o: my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that O <br /> o <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> N <br /> SIGN HERE <br /> atu of owner or b g contractor) (date) <br /> ZONING ADMINISTRATO <br /> �-n <br /> TOWNSHIP PERMIT MAY BE REQUIRED p p u noon m <br /> ooc0000 <br /> 000 0000ln <br />