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01 1 Cotr) + �, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS w 3 <br /> _ o <br /> TO TFiE 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 0 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 a pC <br /> tions of the State of Wisconsin. p r^ <br /> /77)1[6 _ V 1 <br /> OWNER(Please Print) Contractor or Surveyor or Agent1161112 �t a F <br /> I <br /> AddresPAddress <br /> �>� <br /> City,State,Zip Code City,State,Zip Code I g- <br /> Telephone Telephone 0 <br /> Gioia) � <br /> EmergencylFire No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`.- <br /> N <br /> Addition Privy Moving Subdivision g <br /> Structure Use: Kyll o o <br /> (family omelcabin, arage,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. r <br /> 5. If, separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by J <br /> the owner. n <br /> 0 <br /> PLOT PLAN 'R N <br /> Z C <br /> o n <br /> 0 <br /> O <br /> a <br /> f <br /> Q <br /> � o <br /> N <br /> O <br /> 7 <br /> m <br /> O <br /> ^ <br /> Z <br /> C <br /> N a N d O a W m <br /> n aa0o 0n-. m <br /> 0 <br /> N: [ m <br /> �€ m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0. o_ <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- $ 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 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.1 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 /> SIGN HERE � <br /> (signs e f owner o ilding contractor) <br /> (date) <br /> of o <br /> ZONING ADMINISTRATOR �� r4i ' c,f <br /> N ti� <br /> TOWNSHIP PERMITS MAY BE REQUIRED o�Nm m <br /> 0TIC)000N <br />