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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m S <br /> located-as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 'J <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 /> /J•�L�'jf �/�rry �UhyEI(/ �l✓/�,�TyLfJicrj ��t.Df=.e S its C fD n <br /> OWNER(Please Print) Contractor or Surveyor or Age/nt�J n ( F <br /> 35r21t. <br /> Addddress Ad ress _n, <br /> City,State,Zip Code - City, State,Zip Code <br /> J�✓rl/E�VIC7 l�r S L iLS 7'y yrs Z �`/"" 37oB <br /> Telephone v Telephone <br /> C� S� 3 �9 <br /> EmergjylFire No�n�oad Narrte �y <br /> .7//Q[Q �' .ss !✓rimae- <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary FillinglGrading Camping Unit <br /> (l <br /> Addition Privy Moving Subdivision $ o <br /> v <br /> Structure Use: ta""r l(�`/S(t-- "-Qucw" — GaJY'OU,-, 0 0 <br /> (family homelcabin, garage, type of addition, etc.) a <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 lank(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 /> PLOT PLAN / a I` <br /> o Q <br /> ��s5 !ns � ✓' 'S C o <br /> 71 o aJ <br /> j b lz e <br /> K,2r C o14 ' <br /> FS ` <br /> ail °_. <br /> 0 <br /> �0,� � J9 UyT/o•� o. <br /> �/ �- aS'vr Iuclt.,clt� <br /> N Z <br /> All <br /> ue <br /> / ✓ �/-h»r !J(.0 t r'°N Dm y(n r D D W -0 <br /> Ll P: m <br /> LA P � p <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- p o_ I y <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 an accompanyingschedule and I further declare that I recognize that this infor- <br /> mation <br /> N : o; <br /> PP (� 9 Y ) 9y <br /> I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 /> SIGN HERE <br /> (sign jf owner orby�y/Ic�'g contractor) (date) I o <br /> ZONING ADMINISTRATOR;?'`.�L� �'-��� •O o' o <br /> N N O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED WN m m <br /> b0000 <br /> 0000 o 0 <br />