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C5f c� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 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 :R m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m � r h <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n V <br /> dog�of the State of Wisconsin. � rn o <br /> ICo9 eh .S�llnev /U�u/ U�d QLD Llaysf nldrtiv 1 f�uLL� <br /> OWpNNE (Please P}r�''t ll� Con actor or Surveyor or Agent rT_ �- F <br /> !)IaZS (l�66 /VS /0,FL UPJ? Sr '}- m <br /> AXqred ress � 1 <br /> oas6s t�i"/6n /1Z/iNw, SS�fL� A�iAk L)/Sc' SYJf53 <br /> City,State,Zip Code City,State,Zip Code <br /> his— y� z <br /> Telephone Telephone <br /> fiRE No, TZ_ 551 <br /> Emergen ylFir'e'No. nd Road Name <br /> TF_ IVI.0 S Zl T � l� <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for. o 0 <br /> New Building A Sanitary Filling/Grading Camping Unit 0 .`.- <br /> w r <br /> Addition Privy Moving \ Subdivision g Q <br /> Structure Use: <br /> (family home/cabin, garage,addlWon,etc.) O <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). o <br /> 2. Show the location of the well (W), septic tank(ST),and drainfield(DF). ,J <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. 1I ~ <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 lake, 0 'T <br /> river or stream, it applicable. X <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 0 <br /> the owner. <br /> 71 3 N <br /> PLOT PLAN Z o <br /> P n rf <br /> 0 V' <br /> a + <br /> -to <br /> 1 <br /> t © � <br /> V w <br /> � U <br /> �Z <br /> � <br /> r <br /> A csy�o act <br /> $� 'nm sap <br /> �rt�� TzF A-K�= o <br /> L m z ; <br /> [ m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all Informs. <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 m <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- i 8.Pplication.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. m m^ <br /> N 3 NJn : <br /> 5d y Hm �: <br /> SIGN HERE 7- 3 - <br /> ( ' n Lure of owner b ding contractor) (date) ' 9: <br /> ZONING ADMINISTRATOR <a I E <br /> rAH -n <br /> TOWNSHIP <br /> TOWNSHIP PER S MAY BE REQUIRED $$$$$$N <br />