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)� , <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3. 0 _ <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- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions of the State of Wisconsin. �� <br /> LTF'61VZ: �cN,�lf Y5a5�� a o <br /> OWNER(IPJ/pAasse FPrint Contractor or Surveyor or Agent f <br /> AdQress Address <br /> City,State, ip Code City,State,Zip Code <br /> �G7z) YJ7 iz9� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Nisfc�y /a/Q-ti 11V-77 1131Z-51.5- '% %z AVAF <br /> Legal scription (as indicated on tax statement) <br /> Permit(s)Applied for: .". 0 <br /> New Building — Sanitary Filling/Grading Camping Unit m <br /> Addition Privy Moving Subdivision o 1 <br /> —Yno v <br /> Z <br /> Structure Use: G v° <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 /> Show the location of the well (W), septic tank(ST), and drainfield(DF). <br /> how 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 /> A. 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 .I! �p w�-,oY to <br /> See_ 50.1 Test J_dkE ad-( 144ev- v✓�P o n �� <br /> 5 <br /> 0 <br /> 1 <br /> m <br /> n <br /> 0 <br /> Ea Hid 0 <br /> 0 Perrrlir4-- $f is X01 , <br /> v 4— LD Fr f/8 '1N ayDfs"—� <br /> H 3 <br /> M N r D D <br /> (. OUN7 LD. a o"fD <br /> < c w o' <br /> LJ iYUQ4.q.p 7b Mee- ' Wuc¢ 'r {"e� LUrC/^.c (.w JFK/ �© I o o m ? <br /> � as I � � ; m; 70 <br /> IJ �jP ivJ yw,S�r�T' c,i�vpleSSu-e Sjfif — 17= Jcw Yt ° m <br /> Ci n <br /> o: 0 C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 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- o 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 described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (si at re of own or buil ng contractor) (date) <br /> ZONING ADMINISTRATOR <br /> o: 9yof, <br /> Nc^nI�NON ��IQFm <br /> TOWNSHIP PERMITS MAY BE REQUIRED ofao coo oo oo?o m <br /> `'lo o U) <br />