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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator V l � 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions o he State of Wisconsin. H o <br /> nryA. Y d`t10n se ^ o <br /> O (Pleas 'nt) Contractor or Surveyor or Agent <br /> SQMc m _ <br /> m <br /> A d ss Address <br /> N SS 03 co ,m e <br /> Clity,State,Zip CQde City, State, Zip Code <br /> AI 2— 3M-�rJ� Bf 5 Cit.— t <br /> Telephone Telephone <br /> c�E fid. C ) <br /> Emergency/Fire No.and Road Name <br /> ' �l/ . TmSenenec . <br /> L�egOaDescipt on(( md �ed cn� tateient) <br /> /7(,t// ^fur^t.f/-C�Oa /, <br /> Permit(s)Applied for: �D ,q <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Movinpg. Subdivision o <br /> Structure Use: `A /9 Ile _T_ Ae�P� t wry o ° <br /> (family omelcabin, garage,type of addi n,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 (", 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. 'r., <br /> nary high water mark of lake, river or stream, if applicable. Vi <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. 0 <br /> 0 <br /> PLOT PLAN -o N <br /> Z <br /> C <br /> e 6law.40LIPt �, a <br /> N <br /> O <br /> 4,' r <br /> Jr CA !V <br /> klot Flo' �P (n%�fI Ls � ll9 <br /> � o <br /> Z <br /> � <br /> \ <br /> 60' <br /> l••J/''iw`.1. m c .m m n a c m <br /> 42 <br /> v °100 =33 <br /> N w O m <br /> O O'. <br /> Saini-Ldry Peefn -F* 171-1 m <br /> o: <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- 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 coualy officials charged with administering county ordinances or other authorized person to have <br /> access to the above de ri d p emises at any reaso ble time for the purpose of inspection. <br /> m <br /> SIGN HERE S c I f . E . ` <br /> (sign r f 'I II '� ate) ' o <br /> ! <br /> 6 <br /> ZONING ADMINISTRATOR ` o <br /> T <br /> N N O N <br /> UO <br /> M <br /> TOWNSHIP PERMITS MAY BE REQUIRED � � c.0o 6 o 6 c.0o o' m <br /> 00000= N <br /> a4T q_38 <br />