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Ori cavy l <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> w <br /> 0 <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 n p(I <br /> tions of the State of Wisconsin. o <br /> OWNER(Please Print) Contractor or fyAgent <br /> r�/ � � /C7a2T' Fi / RC P/ej;' X <br /> e- m <br /> AAd gess Address <br /> 6k*42&igjn f A ek fn /1/7 ✓t w tom: SS�b'3d <br /> City, State,Zip C&de 3,$'-�j/ 3 City,State,Zip Code <br /> 412 - X93- yo 59 tis - as.- .a.RS7 5 <br /> Telephone Telephone R <br /> P/L;✓/9r� <br /> Emergency/Fire No.and Road Name ''] <br /> d Le) ' oc , sk' ZC <br /> L�Description (as indicated on tax statement)AU&1Z yV r7jr 0,1v —7, o <br /> Permit(s)Applied for. / G <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`.- <br /> N <br /> Addition Privy Moving Subdivision o o � <br /> 1/ T <br /> Structure Use: A3oaT f✓o0 SC )� a2r p o <br /> (family home/cabin, garage, type of addition, etc.) m <br /> a <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 b <br /> the owner. t p <br /> PLOT PLAN N e U eGa 1+0.��F o— TN I�r._Psf 2,J�f ✓Yi,�/ O f-f"''V.N't U � Imo,� r o N <br /> N C lir-�t-, 4)AX �� e � {3,)"T 14V Vu-a( 15 <br /> 1 C.� n <br /> f 5. <br /> $� U o <br /> fi <br /> /o° t o c <br /> f <br /> p <br /> ( � o <br /> vk o <br /> 1 N< <br /> 33 <br /> � c <br /> ga ! <br /> V n <br /> mvmr DDtDM <br /> ri m c 0.m m o n o <br /> n c< oo0n-. m <br /> Y 1 <br /> u O O <br /> J <br /> Win; m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- p o :'o;y o :o S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy ofall informs- o'o 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 n <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 desc ibed premises at any reasonable a for the purpose of inspection. <br /> SIGN HERE C1 <br /> (at atur of owner or bu 1 contractor) (date) E o EB o <br /> ZONING ADMINISTRATOR <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED P'NPPooR m <br /> 000000 <br />