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,I <br /> Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator d V o 0 <br /> APPLICATION FOR - LAND USE - PERMITS . 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 c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. <br /> 11151,C"�i <br /> a � o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> Address Address <br /> City,State,ZCity,State,Zip Code <br /> ip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building ,L�-!„/.�J Filling/Grading _..` <br /> Addition Moving <br /> Sanitary Camping Unit o ^, <br /> 0 4 <br /> Privy r Subdivision <br /> Structure Use: <br /> Z <br /> (family home/cabin,galage, addition,etc.) o v <br /> m <br /> z <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). r <br /> 3. Show the location of any lake or flowage-if within 10Do ft.and the location of any river or stream- if within 300 ft. o <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. o <br /> PLOT PLAN 3 <br /> Z o <br /> 4 o x <br /> � R <br /> y ST <br /> -- - <br /> N <br /> AUG 1989 <br /> c <br /> z <br /> W Fr�L � <br /> Dy � CO <br /> 3 n V-W E.AM r <br /> n o'< > > n a <br /> « : m <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 any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing a <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE - 711 <br /> gn of ow building contractor) (date) <br /> d <br /> ZONING ADMINISTRATO ^ o o <br /> -n <br /> ` NNON <br /> TOWNSHIP ERMITS MAY BE REQUIRED - u,u,v v m <br /> 0000 Cn <br />