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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 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. am E <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 a iJC' <br /> tions of the State of Wisconsin. v <br /> y <br /> tmn W 4rhY r Sa rinhS Qtlti $ r o <br /> OWNER(Please Print) Co ractor or Surveyor or Agent a f <br /> �( I n l4rgv ( c S7 8aX Ss9 <br /> Addr ss Address <br /> S �4 4 L hM .� . S-3—/0 3 GQ�a Aj W f_ 41 3 <br /> City,State,Zip Code City, State,Zip Code <br /> 1 <br /> Telephone ele —� <br /> Emergency/Fire No. and Road Namek"11., formol Of I WWI if I <br /> • 1 <br /> Legal Description (as indicated on tax statement) ao <br /> Permit(s)Applied for: o <br /> New Building Sanitary _ Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision o 0 <br /> Structure Use: J �Y v rQ " �'^ J'�i1K.t/ �tLl�l� 0 0 <br /> (family home/cabin, garage,type, f(family home/cabin, garage,type, f add 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 /> 2. Show the location of the well (W), septic tank(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. <br /> 0 <br /> PLOT PLAN 3 <br /> 9 (n <br /> 9 d c <br /> o Q <br /> a <br /> ) / J <br /> P o <br /> r m <br /> n_ <br /> rl o <br /> J <br /> o r <br /> O <br /> Q C D <br /> I�I <br /> V <br /> I <br /> >7 m rDaC <br /> p c n ac <br /> o Cr oa-. m <br /> o O J Tj <br /> ry O J b <br /> P O 2 1 <br /> O J : <br /> rn: M <br /> CZ j M <br /> o: 0 <br /> o: o C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best ofmy knowl- <br /> edgeand belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o In <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this infor- <br /> PP (� 9 Y ) 9 ! m ; <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 /> T <br /> N <br /> (A <br /> SIGN HERE <br /> (si at re of owne uildiinngg contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> o o <br /> w T <br /> TOWNSHIP P RMITS MAY BE REQUIRED N� ��oaP m <br /> ooO000 <br /> 000000YA <br />