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Grp CCmP <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,WM 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <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- <br /> tions of the, <br /> State Wisconsin. v CA <br /> ri ��ss <br /> OWNER(Please/Print}) c. Contractor or Surveyor or Agent n f <br /> Adres Address v <br /> S t17l�lur l/Xii <br /> City,StaC _ v City,State,Zip Code <br /> Ldj . G <br /> Telephone Telephone <br /> 1 <br /> Emergency/Fire No. and Road Name <br /> �lf �/�i & P F QC{ <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: o N <br /> New Building Sanitary — Filling/Grading Camping Unit H -�-' <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> �fJ �R� ONm z <br /> v <br /> Structure Use: o <br /> (fay <br /> home/cabin, garage, type of addition,etc.) _ �- <br /> Directions for plot plan drawing: n� <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. o <br /> 3 <br /> PLOT PLAN Z <br /> o n <br /> 0 <br /> See. ��chek � �6 w ' <br /> t <br /> 0 <br /> N � <br /> O <br /> O <br /> N � <br /> n <br /> /v Z <br /> l 9 <br /> C <br /> W N N D D W -o <br /> ac.c. m i <br /> o y m <br /> o A <br /> 0: C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowly <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- �� o C <br /> tion contained in this applicat�r pcludin 1 any accompanying schedule)and I further declare that I recognize that this infor- m , <br /> mation I am providing will be rp ad upon by tW.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. lagree o permitcounty o ficials charged with administering county ordinance or other authorized person to have <br /> access to thea ve described pre ise t any reasonable tiMY16r the purpose of insp ction. <br /> / T <br /> N 2- <br /> SIGN HERE ' �+ <br /> (signatu a of owner r bu�ding ntractor) (date) <br /> ZONING ADMINISTRATOR <br /> v -f <br /> TOWNSHIP PERMITS MAY BE REQUIRED N v v o o m <br /> o�oogoofA <br />