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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z <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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 0- <br /> tions of the State of Wisconsin. m o <br /> © rccnfft,7j F, N <br /> o <br /> OWN R(Please Print) Contractor or Surveyor or Agent o :E <br /> 3o 30 l 4:ml fr <br /> Address Address <br /> t2I:N 6 oRY 1A) 54f <br /> City,State,Zip Code City, State,Zip Code <br /> 7Js-CcsG -3s44- <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> o <br /> Addition Privy Moving Subdivision o <br /> G�2RGE R� <br /> Structure Use: 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). 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 by <br /> the owner. <br /> 0 <br /> 3 <br /> PLOT PLAN A o f N 6 Z 0 <br /> 0 n <br /> jN <br /> (1 I O <br /> ( e <br /> f N <br /> I — o <br /> �g <br /> A z8=x 4b' 3 <br /> � o <br /> f < < <br /> r = 108 •c <br /> !8 <br /> ?'0 <br /> 176,10 <br /> mYN c M.m ro 0 a a m A-V � 0 O'eoD0n_ <br /> m a•< - nm »nom <br /> o <br /> Cn <br /> N 2 u O O <br /> N <br /> m <br /> «r i m <br /> Q �0 0[ O <br /> ISE E E 0 E 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 informa- jX <br /> 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 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 /> m <br /> w <br /> SIGN HERE <br /> (signature of o ner ori�building contractor) (date) ; o: $ <br /> ZONING ADMINISTRATORit I <br /> VII , IV NOIJ��N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 0000 oSS !/1 <br />