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Burnett County 7410 Co. Rd. K, 11102, Siren, WI 54872 Office of Zoning Administrator iv � a o <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 /> ° S <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 Courty Ordinances and the laws and regula- 3 n OP <br /> tions o he St e o Wisconsin. O <br /> N d <br /> �7 oac-A ��� a � o� <br /> OWNER(Pease PrP Contractor or Surveyor or Agent o <br /> Address Address 1 <br /> City,State,Zip Code City,State,Zip Code <br /> f 41 <br /> lephone=13a Telephone � <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving R <br /> Sanitary Camping Unit n o <br /> Privy Subdivision <br /> s <br /> Structure Use: � <br /> (family home/cabin, garage,addition,etc.) o <br /> a <br /> m <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 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 <br /> the owner. 6. Provide legal land description. 0 <br /> o <br /> PLOT PLAN <br /> o ry <br /> c <br /> Z o- <br /> o n <br /> 0 <br /> `1 <br /> e <br /> l <br /> 0 <br /> N O <br /> O <br /> 7 <br /> m <br /> O <br /> T <br /> OZ O <br /> er�eu? d l��ro /50 <br /> 3 y 30 <br /> pec U�c 1 9C// Z <br /> � mv(nr DDOo� <br /> mc .m m n as0 U< m <br /> m <br /> =am =am <br /> � yo �� 3 <br /> m <br /> m <br /> n ; <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ^o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that n Im <br /> PP (� 9 Y ) 9 [ a <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a ap oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing y <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> f� N <br /> yy <br /> SIGN HEREIN /l a-, Ao 11\1 ccU/ <br /> (sig o owner or building contractor) (date)) <br /> ^\ [ <br /> ZONING ADMINISTRATOR <br /> -� <br /> `r <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />