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O 11 COI)TI'3 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn m o 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 y <br /> 0 <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 a _ <br /> tions of the State of Wisconsin. o <br /> N � <br /> I <br /> C A C1G � -.I FR rJ I'E's M6 2 2L S C�S7Tjr•N (L ,� <br /> OWNER(Please Print) Contractor urveyor or Agent a f <br /> I.5 W ss`r1=rtfn.t HV. N , X510 25947 41,2 35 <br /> Address Address <br /> ST. PAVI MN. 55102 wFc3srr-z to 59893 <br /> City,State,Zip Code City, State,Zip Code <br /> r-&I Z - Z93-0 180 71s- 8(,r. — S18r <br /> Telephone Telephone <br /> F1 �� � _752.2 YCLL00j LPtKE (ZO Co FF LA+jnIA0 <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 3 �- <br /> r <br /> Addition Privy Moving Subdivision $ o <br /> Structure Use: ( ARA G E- <br /> o a <br /> (family home/cabin, garage, type of addition, etc.) m <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 /> 3 <br /> PLOT PLAN <br /> o n <br /> 0 <br /> 1 t o <br /> .� 50 <br /> O O <br /> C, <br /> 3© <br /> a <br /> t?FA VIC <br /> IN <br /> .i NJ 75 ,a ty <br /> l� Pesos ° <br /> D <br /> N c MW (Di acmes <br /> 0 a< = 0 0 a-. m <br /> m a� - a m � <br /> a < "cyo=' 3 <br /> N N O J n <br /> O p : <br /> CO <br /> C D <br /> 4 o E C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E i : E 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- c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o: O <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 /> OCL 11 13 g`� m " <br /> SIGN HERE <br /> (si n lure of owner or bldilg contractor) (date) `: o k E [ o <br /> ZONING ADMINISTRATOR <br /> w -n <br /> N N O N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED p p p u o o p m <br /> 000oa00 <br /> 0000000fp <br />