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,Surnett.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 /> 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- m <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. v 1 <br /> A �n Z_ c'Dze-rX?1.4 y w <br /> C <br /> t� �i Pi m . O <br /> OWNER (PleaseJJJ���rint) L �f Contractor or Surveyor or Agent a £ <br /> y m <br /> Ar5pC�6s�-e Address <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone <br /> Telephone <br /> P <br /> 1 <br /> Emergen y/Fire No. an�oad Name J C <br /> 7/� (�1r Q <br /> rQ / j 7 <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> Addition �lI-FfJ_ , 'i 3 Privy Moving Subdivision o <br /> ] ll l <br /> Structure Use: o � <br /> (family ome/cabin, garage, type of addition, etc.) 'n_1_z <br /> Directions for plot plan drawing: <br /> X/ <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 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 <br /> the owner. c7 <br /> 0 <br /> 3 <br /> PLOT PLAN R rn <br /> Z = <br /> o Q <br /> _ a <br /> 0 <br /> o <br /> 3 <br /> 0 <br /> m � <br /> X N r D D m -0 <br /> 0 = .00 <br /> 0 a c <br /> 0 Cr >_> m <br /> S a <br /> O O 3 <br /> N O MOO <br /> Z 0 . � '� <br /> w: T. <br /> C m <br /> o : O <br /> lJo: o'E C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl y <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 m <br /> tion contained in this application(including any accompanying schedulej'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 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 /> _ N <br /> Q m <br /> lT <br /> SIGN HERE <br /> (signatu of/owner orb ntractor (date) <br /> ZONING ADMINISTRATOR <br /> N N O N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED )v v p v o o N <br /> ✓0000000fm/l <br />