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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W M 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 0. <br /> y <br /> TO,THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- T <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. <br /> N d <br /> N <br /> n 0 <br /> OWN (Please ri Contractor or Surveyor or Agent �3E <br /> Add r s Address <br /> City,$la��Zjp C2 „— City, State,Zip Code <br /> Telephone /I ( � C� Telephone r `l <br /> V 1 <br /> Emergency/Fire No. and Road Name <br /> CIO <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: `^' 0 <br /> o <br /> New Building Sanitary <br /> Filling/Grading Camping Unit <br /> ' <br /> `^ r <br /> Addition Privy Moving Sy"wise n o <br /> �i �a� TrC1� tin 11 rr, o <br /> Z <br /> Structure Use: <br /> O 9 <br /> (family home/cabin, garage, type of addition, etc.) 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 /> 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. 3 (f,` <br /> PLOT PLAN o V w G <br /> Z c <br /> o I o <br /> N <br /> ( J <br /> s <br /> N <br /> I <br /> V N <br /> `J\ <br /> N ly, <br /> O IAV <br /> J <br /> J <br /> N � <br /> ~ I� <br /> D 1 l D <br /> C �. oloU <br /> 10, c$0. nacDAmnO J <br /> wS m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- O <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 described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> N <br /> SIGN HERE 4 <br /> (signaty of caner or buil contractor) (date) 0i o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N� 00N m <br /> 0C 0000fmd <br />