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0k CafylI <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 0 <br /> located as skown 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 a <br /> tions Qf State of Wisconsin. 0 o <br /> � f- J 4c,&7 <br /> o <br /> OWNER(Please Print) y Contractor or Surveyor or Agent o r <br /> Ad <br /> dr ss Address ( <br /> Mv SC' v <br /> City,State,7jp Codjw City, State, Zip Code <br /> pis - res,C- 76 a 1 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> - a <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: n t7 <br /> 0 <br /> New Building X Sanitary Filling/Grading Camping Unit 0 .`.- <br /> r <br /> Addition Privy Moving Subdivision $ o n <br /> P <br /> Structure Use: o o <br /> (family home/cabin, garage, type of addition,etc.) <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). <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 lake, river stream, if applicable. <br /> submitted <br /> a <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. o <br /> 3 <br /> (PLOT PLAN <br /> Z 0 <br /> V 0 <br /> O <br /> W 1 v <br /> 4 \}t(ll <br /> ld �Pk� G <br /> Ld <br /> walk 6 f <br /> S <br /> 4• <br /> Z <br /> 9�77 / ]0 (n Mca mprDDWm <br /> / (� ry c N r O n c <br /> n a< =a m =a m <br /> m n� 0 0 »ate <br /> a < 2 c:0 <br /> n ? 0 o 0 0 <br /> 0 0: 1 <br /> UI <br /> M <br /> m <br /> o D <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- 0 m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> LA $ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 113 a <br /> V: <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 /> SIGN HERE l ! L <br /> (signature r or bu' g contractor) (date) <br /> ZONING ADMINISTRATOR <br /> T NSHIP PERMITS MAY BE REQUIRED m <br /> oo� 000y <br />