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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o 0 <br /> APPLICATION FOR — LAND USE — PERMITS d o <br /> y <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'o 1 .� <br /> Iocatc,d as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- c V t <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. <br /> N v <br /> C / <br /> a f <br /> OW R(Mase Print)�l Contractor or Surveyor or Agent ^dp � <br /> � <br /> i <br /> Address <br /> Add s ,�{�/ M (�- <br /> "' -I��j I I ' !�3 City, State,Zip Code <br /> e }16.11 <br /> City Stat Ziee,,Cod <br /> S 1 <br /> Telephone� Telephone I <br /> Oak La Ke Q - <br /> Emergency/Fire No. and Road Name <br /> 0 <br /> Legal Description (as indicated on tax statement) <br /> Permits)Applied for: o <br /> o` 0 <br /> New Building Sanitary FillinglGrading Camping Unit 'w <br /> Addition71 <br /> Privy Moving Subdivision.� J Z <br /> S I�hI11 rtN�l V'1,��� `� <br /> LS Io a <br /> Structure Use: Of addition, etc.) �- <br /> (family)homelcabin, garage, type � n\ � <br /> Directions for plot plan drawing: �lJ <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NB) and indicate North (N). r ', <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 - earn -if within 300 ft.g to ordi- <br /> if within 1000 ft. and the location of any river or strJ <br /> 4.Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildin <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 o J, <br /> the owner. 3 <br /> a N <br /> PLOT PLAN o cr <br /> 9J s <br /> y <br /> i I � <br /> a <br /> e pfache4 Dccao)Pl6 S <br /> si D) sz— : <br /> (r y <br /> �l <br /> O0 <br /> ro O <br /> J_ <br /> � J <br /> N <br /> I Z <br /> 'IIrD'�r� <br /> I <br /> m N N DDCO "D <br /> c = w n ac 0 a <<< 2 nn <br /> — m <br /> 0D,n' <br /> P <br /> 2 m <br /> (Z ro: C E A <br /> SJa, o i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Go i , i p i M <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o O <br /> 6 : <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- a , <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. <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. lagree 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 <br /> m <br /> (l fn <br /> +ERE 0 <br /> 1datb) xl�. V : N <br /> (signal a of owner or ildi contractor) ; o: o <br /> p� fie- o: o <br /> 9NISTRATOR �� T 12Po�)I' <br /> rid <br /> NN N ——Nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED g 800000 N <br />