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1P <br /> Burnett county 7410 Qo. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z _ a <br /> YO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> 1JN <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- N m <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. - 21 <br /> N d <br /> n <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> Address Address U <br /> Sf ion ' /l�i� 55375 <br /> City,State,Zip ode r City,State,Zip Code <br /> ��/,�-� <br /> Telephone Telephone <br /> EmergencylFire No. and Road Name <br /> /07"'/ 2;�6nr lo/rc dram �qd a{�C'�der /o� S 5f���- 54!`y sec /7 rmn <br /> Legal Description(as indicated on tax statement) Rgp9C /5 ;5W"SS n <br /> Permit(s)Applied for: » o <br /> New Building Sanitary FillinglGrading Camping Unit — uo', <br /> Addition Privy Moving Subdivision o <br /> �j <br /> Structure Use: 0 <br /> (family homelcabin, garage, type of addition, etc.) m <br /> a <br /> r <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). <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 � f -P u+ <br /> Ptrvn< /Yla / 5 t/� Qc� 3/ J 0 <br /> ���er S ari� m <br /> /99G <br /> I <br /> L, <br /> i <br /> o �; <br /> I <br /> 0 <br /> o <br /> N � <br /> » I� <br /> Z <br /> I D <br /> �I <br /> D Wn U)r- DDtD -0 <br /> N a .O1 N 0 ac <br /> o Q< Do oa <br /> -. m <br /> m <br /> �i m <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 informa- ; g C <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 <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 E :'iv: <br /> access to the above described premises at any reasonable time for the purpose of inspection. �� <br /> m <br /> / N l <br /> SIGN HERE <br /> (si at a of o r building contractor) d"ate)_._ XJ o-m <br /> ZONING ADMINISTRATOR -M, moi <br /> o u m <br /> TOWNSHIP PERMITS MAY BE REQUIRED 2 d IN u <br /> 0000 oog y <br /> i 60000 <br /> n <br />