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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> a <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 n C <br /> do f the State of W'sconsi 0 0 ^ — O <br /> 'fJM97- a � } D ZIEjN�� C Lj �F tGQ� 5 <br /> a O <br /> O y,(�a PrinXX g Contractor or Surveyor or Agent E <br /> � p f � o <br /> Addres �— Address <br /> ASQ T E t S4 gA3_o�ISo <br /> Clty State Zip Code City, State,Zip Code <br /> � $tob _ y643 <br /> Telephone Telephone (� <br /> Emergency/Fire No.and Road Name T <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit m »- <br /> r <br /> Addition Privy Moving -/ Subdivision o ° <br /> Structure Use: • • ^ '� o Oil <br /> (fami home/cabin, garage,type of addition,etc.) l/ C ,j... <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 a N <br /> a <br /> I�NDI� <br /> (J o` <br /> I � <br /> t <br /> n <br /> (n <br /> O � <br /> G 0 <br /> 0 <br /> 0 <br /> N VJ <br /> 0 <br /> � Z <br /> \NI 7J <br /> 1 <br /> m c M(0m nno9 <br /> m n� 3'nm amSm <br /> O O <br /> 5AM� A E1. l Z o -� <br /> Ln ' :�O N: A <br /> r 1 V N� <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- M <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 0= ao 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 <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 :civ <br /> access to theabove mises at ny reasonable time for the purpose of inspection. <br /> m N: <br /> m ice: <br /> N <br /> (A :t 1:0: <br /> SIGN HERE "°1`0' <br /> V:3: :ON <br /> gnatu owner contractor) (date) o v: :m o <br /> ZONING ADMINISTRATOR �- o:h; `nom <br /> SAN[NIiN(NT O 0[ <br /> TOW SHIP RMITS MAY BE REQUIRED ho 0 0 0 0 0 <br />