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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m ' o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <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 CD <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tionf the State of Wi opsin. o <br /> et <br /> //-7////am ;512 <br /> m o <br /> OWNE (Pie a Pr' t) Contractor or Surveyor or Agent a F <br /> m <br /> Addre s Address m <br /> City,Stpte,/Zip joQe4 _ aW City,State,Zip Code <br /> TelephoneTelephone ( <br /> Emergency/-/ire No. and R ad Wame <br /> //r/���m� �Z�S V162 5,?3 T40-& e//1.c/ <br /> Legal Description(as indicated on tax statement) p <br /> Permit(s)Applied for. o <br /> New Building Sanitary FillinglGrading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision g o <br /> Z 'o <br /> Structure Use: ° $ <br /> (family omeicabin, qfrage, 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). o <br /> 2. Show the location of the well(W) septic tank(ST),and drainfleld(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 fines,(b)building to center line of road,(c)building to lake, <br /> 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. 3 rn <br /> PLOT PLAN <br /> A o � <br /> a � <br /> J m <br /> Gi l 0 <br /> m <br /> o <br /> e <br /> Z <br /> f <br /> f <br /> my Fj. a <br /> CTmma <br /> m <br /> CL'm <br /> LL <br /> to <br /> CA ci O <br /> . <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- =i E 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 2S w In <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- i $a $ <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. m ? O~o i <br /> N R i <br /> i <br /> SIGN HERE ' Vow g . <br /> (sign of owner or buil 'n onlractor) (date) <br /> $i E <br /> 'ONING ADMINISTRATOR - � `• ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED Boom <br /> 8 8 888fn <br />