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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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 <br /> tions of the State of Wisconsin. U 1 <br /> M <br /> N �, "e,� . <br /> o <br /> f <br /> OWNER(Please Print) Contractor or Surveyor or Agent o J <br /> Address Address t <br /> City, State,Zip Code J City,State, Zip Code <br /> Telephone ItTelephone <br /> JAMA <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: O <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit J <br /> y J <br /> Addition Privy Moving Subdivision o 7� <br /> Z 'o <br /> Structure Use: <br /> (family homelcabin, garage, type of addition, etc.) 'D <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 1 <br /> the owner. '� v <br /> Vr` 3 <br /> PLOT PLAN �}(ZpSuK: v to <br /> 7 P � <br /> Na afN >—.r1tc� �G�l� <br /> < i ��� o c <br /> I �r o <br /> CA <br /> a d <br /> I , N 44 0 <br /> iii Z`� - <br /> Q it <br /> I <br /> 1 m w n c c - <br /> IV m n`—'nm nag <br /> uNovi9 d <br /> ` m <br /> o: C <br /> o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o : J : y <br /> all informs- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of >" m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $E G <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 fficials charged with administering county ordinances or other authorized person to have <br /> access to thea described pr ices at any reasonable time for the 4pur9psne of iection. T <br /> A <br /> � i <br /> SIGN HERE <br /> (signature of owner r bui ding contr ct ) (date) o o <br /> o: <br /> ZONING ADMINISTRATOR <br /> 062-0N��rnNm <br /> TOWNSHIP PERMITS MAY BE REQUIRED noo6666 lA <br />