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()I I cc= 7 7 1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d � a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. _ <br /> o <br /> TO THE 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. `- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n 1,�c <br /> tions of the State of Wisconsin. V <br /> D�a'R SLC l'�LC/mss �ce��tres)✓L <br /> a O <br /> OWNER(Ple9ase Print Contractor or Surveyor or Agent o <br /> 6 !0� �� ,fl/PdUC Stuzvc� � f <br /> Addres Address N <br /> .s J <br /> City,State,Zip Code City,State, Zip Code ^r' <br /> AP4,' - -�122Cj J <br /> Telephone Telephone <br /> -D <br /> Emergency/Fire No. and Roa Name <br /> Got � - (1,S'M /jam l <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: `» <br /> New Building Sanitary Filling/Grading Camping Unit m »' <br /> Addition Privy Moving Subdivision o ° ` <br /> ✓A //�M S �i n trt� ✓1 v �+� <br /> Structure Use: m <br /> (family homelcabin, garage, ype of addition, etc.) _ � <br /> Directions for plot plan drawing: N <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). ^°r. <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 O \ <br /> the owner. o v <br /> 3 <br /> PLOT PLAN o N <br /> Z <br /> o Q <br /> �y n <br /> t <br /> O N <br /> 0 <br /> f <br /> � n <br /> w � <br /> Seg lJ�/�Na ��— � • m <br /> e � 0 <br /> � l <br /> N C � I� <br /> O <br /> 7 �V <br /> J N <br /> � p <br /> Z <br /> a <br /> 1 <br /> oyi ori cDi a_ <br /> = a� n mac n S <br /> NCZ Do <br /> 3 <br /> N ? ; o <br /> Z o zi i -1 <br /> i m <br /> V �z Off: i o : [ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ,5= o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ' o 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 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 /> (D <br /> fD <br /> 2 9D <br /> SIGN HERE <br /> (signature er rilsyn c tractor) (dat ) <br /> Zl. o: <br /> ZONING ADMINISTRATOR <br /> 2 a <br /> TOWNSHIP PERMITS MAY BE REQUIRED y1 N o o N m <br /> LL <br /> 000 <br /> 000 <br /> 00 000 Uf <br />