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L I I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator do a <br /> APPLICATION FOR — LAND USE — PERMITS3. 0 — <br /> d a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m —L- <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. 0 m (,S7 <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 State1 of Wisconsih. \\ <br /> �eCV so \� L� yJ b� d��ehSotJ C <br /> n 0 <br /> OWNER (Please Print) Contractor or Surveyor or Agent -- f <br /> Q IN, <br /> Addre Address <br /> '(1 aS� L t 1n o W-I� ;Z <br /> City,State,Zip Code (�L) City, State,Zip Code <br /> V I <br /> Telephone Telephone DQ -' <br /> 7 <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> Permits)Applied for. 0 o J <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision o <br /> Structure Use: l�� nF / y o 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). 0 <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN p N <br /> Z c <br /> 0 O' <br /> n R1 <br /> 0 <br /> 0 <br /> w co <br /> o <br /> 0 <br /> S <br /> 0 <br /> �v <br /> ` J 9 <br /> G <br /> D > Ooh <br /> 0 <br /> n Q< 0 0 0 <br /> SD. a`c <br /> T.om p <br /> Z m <br /> 0 <br /> of i i Ni''' EJS <br /> w 2 m <br /> n` 0 : Q <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 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. 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. l agrea to permit county officials charged with administering county Ordinances or other authorized person to have <br /> access to the above descri premises at any reasonable time for the purpose of inspection. <br /> T <br /> N i t t <br /> S ^ € <br /> SIGN HERE /C' <br /> ature of own or- i ding contractor) (date) \I; E o ': ! o <br /> ZONING ADMINISTRATOR <br /> n <br /> TOWNSHIP PERMITS MAY BE REQUIRED NmcN /r <br /> N(T tTNO r/pp <br /> l/ OOOO O�J� <br />