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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and o <br /> N <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. p <br /> N � <br /> S`j rl n/ ad&64 SPexl �Clo S <br /> OWNER (Please P ) nt for o S eyor o�y+gent a F <br /> CoIVI • t [SOX <br /> Add I�vl` , Ad r/ AmelG /G KJ / <br /> City, State,Zip Code q City, State Zip Code f <br /> ��3 1 <br /> Telephone lF�orRoad m <br /> Telephone (J <br /> T <br /> ay -T37,f/ �✓!� <br /> Legal Description (as indicated on tax statement) 6 ,4417'.f � SY o �d '�((1/y-J�{� p <br /> Permit(s)Applied for: <br /> O fo <br /> New Building Sanitary Filling/Grading Camping Unit ° `- <br /> N <br /> Addition Privy Moving Subdivision o 'Or, O <br /> Structure Use: o 1A(family home/cabin, garage,type of addition,etc.) 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 OF). <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. O <br /> O <br /> ;PLOT PLAN vliLL Qt A— 9 <br /> N <br /> Z c <br /> � o n <br /> 3lif U) <br /> / N <br /> O <br /> 1 <br /> rVkOILD <br /> o <br /> i <br /> 0 <br /> 0 <br /> 0 <br /> ZIP <br /> IIV <br /> N � <br /> t D <br /> L� <br /> X mv(nr DDWy <br /> � , Q2> > onc' m <br /> T � >,51,j6 S'J' ,LLv l4 m arc =0_ =nM <br /> SD. <br /> N C 00 O O ; <br /> _ m i 2 O o fa <br /> Oo : ' ':�.'2 hn: <br /> e Cn <br /> A ,�,,t� 131W �O„ � U) P -C, o <br /> r 470 f`li +S' r«r: � ,�: m <br /> I declare that this application(including any accompanying schedule)he lJ s <br /> s been examined by d to the best of m nowt- e o: in y <br /> Hp: <br /> edge an belief it is true,correct and complete.I acknowledge that am responsible for the detail an c of informs- ;o c: m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize at this infor- i :ac: i C <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue apermit. I o a i <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 /> o:v: <br /> access to the above des i d premises at ny reasonable time for the purpose of inspection. :.. ,: i <br /> N; <br /> A4 040 Z <br /> SIGN HERE <br /> (s' na r ofowner or 'Id' gcontractor) (date) '. oa '. �o <br /> ZONING ADMINISTRATOR <br /> Q y i �o <br /> TOWNSHIP PERMITS MAY BE REQUIRED GNNON <br /> IT(P V7 N O OK <br /> m <br />