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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ <br /> w J t <br /> o <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 J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> tions of the State of Wisconsin. m o <br /> ��L �r� S� i�,�/s �_ s r <br /> N � <br /> C <br /> OWNER(Please Print/) Contractor or S yo ge t • o. - VI-7 FO <br /> S 62 <br /> m <br /> Ad ss -� I Address `- fJ <br /> �i1lSUS�sp G C1 <br /> City,State,Zip Code _ _ 7 City,Stat Zip Co Ob <br /> Telephonei/. Telepho • iF <br /> _26 <br /> 'JE <br /> Emergency/Fire No. and Road Name <br /> Q <br /> Legal Description (as indicated on tax statement) o '� <br /> Permits)9pptred for:—�� n <br /> O <br /> (:_:did_, <br /> Building Sanitary 'Filling/Grading Camping Unit <br /> N <br /> dd,1ion Privy Moving Subdivision <br /> // v <br /> Structure Use: a Bep F o 0 <br /> (family homelcabin, 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 /> 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. r <br /> 0 <br /> 3 <br /> PLOT PLAN o <br /> N <br /> Z = <br /> 0 v <br /> I a <br /> 1 <br /> 3o , + V\ V� <br /> (J <br /> xOal <br /> (�j <br /> I � <br /> ao ? o v <br /> 3e ' + 9.0 <br /> l� w <br /> \I Iz <br /> D <br /> m c 0 c <br /> p _: <br /> N N O <br /> 011: .m O J <br /> OZ O <br /> J Cn i <br /> d C i m <br /> o: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl/--q C/1 0: y <br /> V "+�� [ [ A <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informals , o: m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. L ' C <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. (Y ! n <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this a - <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 /> — / N <br /> A <br /> SIGN HERE <br /> (sig a of owner uildin ontractor) (date) o' c <br /> ZONING ADMINISTRATOR o o <br /> q• Cc) <br /> J O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED V o 0 00� <br /> ooJ <br />