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3urnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrattolr C`( I , _0 o a <br /> APPLICATION FOR — LANLTUSE — PERMITS 3. <br /> s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � N <br /> located as shown herein.The undersigned agrees that all work shall be done In accordance with the requirements of the Bur- w c <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. - o <br /> J2O/ N d <br /> � � NC D. f'.I/i�///tiA ,1.1 _ TilcL PHcLPJ- O C11Lj9 = m <br /> OWNER(Please Print) / Contractor or Surveyor or Agent o ` F <br /> g 1-0k) <br /> m <br /> Address Address <br /> r/ vtS c_ SH 630 DAI Or,(Z y IVIS c_ S r/d'J0 <br /> City,State,Zlp C de City,State,Zip Code SO <br /> 5 w l <br /> ' Telephone Telephone <br /> 16'6,5'6 - 7u-7�1_ I - 71J (, -5 3 .58 '/ <br /> EmergencylFire No. and Road Name R. <br /> ( a <br /> Legal Description(as indicated on tax statement) 1!IS rV Fy J R f)­14 y Is—//Z3 y 7 7o o O <br /> Permit(s)Applied for. S /�t'r'ssy////,���, /f,, A c��//A C S . 770 0 c) (c <br /> New Building Sanitary PC�• Fillingr(radFng' / <br /> Z. ° 2_4 0 0 Unit 0 t <br /> m <br /> Addition Privy Moving Subdivision a 0 <br /> v <br /> ( Structure Use: LA A 13i✓ Utit =-- ��X3 d/ lk�7 6EVo 0 <br /> (family ho a/cabin, garag type of addition, etc. m <br /> Directions for plot plan drawing: C <br /> 1.Show the location and size of all existing buildings (EB)and all new buildings(NB)and indicate North (N). r <br /> 2.Show the location of the well (W), septic tank(ST),and drainfield(DF). 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 litres,(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. na <br /> 0 <br /> PLOT PLAN /��— v <br /> z c <br /> 0 n <br /> ��---� o <br /> et <br /> hL , n <br /> Leap Ck' ' <br /> . -,sf_T <br /> z <br /> 5, 7:^1 _�ZarT0 <br /> _ I ZI27Tr-i- to <br /> TN T _ a <br /> / - <br /> , <br /> /°FT w <br /> a � <br /> c<> > 0nS. m <br /> v < ; me 3 <br /> F : Z o <br /> Z o: 1 <br /> j'�L'(.,1AGC (7e.lvE N' m <br /> O <br /> g ' E o E C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E 0 E 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- = n` 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 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 d ribed premises at any reasonable time for the purpose of inspection. <br /> m <br /> n� m <br /> SIGN HERE L <br /> (s' na re''Z of owner ilding contractor) (date) <br /> I IE o[ ( o <br /> ZONING ADMSTRATOR <br /> -n <br /> �N�oo� m <br /> TOWNSHIP PERMITS MAY BE REQUIRED � � m <br /> SSg$$$$ tn <br />