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of� corn <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z s <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- <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. o <br /> y � <br /> ���ulr lJ. SNtl � i Z S'nyo=at <br /> OWNER (Please Print) Contractor or Surveyor or Agent n F <br /> AKcNr,rl INN 9h- <br /> o <br /> Address Address " I <br /> Wf-8S,ER Wrsc. 5 9fi_3 QZJ <br /> City,State,Zip Code City, State,Zip Code V <br /> Telephone Telephone <br /> 42 /3 AnIC flout )NN Rj)+ r <br /> Emergency/Fire No.and Road Name // ^ <br /> V✓ <br /> Legal Description(as indicated on tax statement) o J <br /> Permit(s)Applied for: L1 2 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`.- <br /> 0 <br /> Addition Privy Moving //�� `' Subdivision $ ^°r. <br /> Structure Use: —Enc atpd `�\ I —I `L7-fit o 0 <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). 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. <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. O <br /> 0 <br /> PLOT PLAN v3 m <br /> Z T <br /> o- <br /> 11 0 <br /> z " TLS r3 A ( s 9J <br /> ,ice �- <br /> - T/ <br /> p <br /> 1 m <br /> �6 r <br /> 0 <br /> JVDt, s W_ R <br /> $ Lief p f v <br /> v <br /> � j bQ <br /> �U <br /> Z <br /> rte- <br /> /1 J \ M W7°dd >n . m <br /> m nom '-mma z <br /> Z <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ' 010' O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I ' :ma <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 i i i env; <br /> access to the above described premises at any r;asonable time for the purpose of inspection. [ , <br /> SIGN HER /,� � /- -2 /' I U �' iia: <br /> (siatur of owner or 'di contractor) (date) 0?3 bo <br /> b: o <br /> ZONING ADMINISTRATOR I oyo <br /> i\o, xT <br /> TOWNSHIP PERMITS AY BE REQUIRED m <br /> 000000 <br /> 000000g V/ <br />