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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 a <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> w 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- a c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 OR <br /> tions of the State of Wisconsin. o (� <br /> I <br /> G,ar I« `Yo nQ m <br /> OWNER(Please Print) n C ntractor or Surveyor or Agent n £ <br /> CCL Rd Noc "Z� is lk'wtp w VI <br /> Address Address :? <br /> (JuUhZe'L wis s483o <br /> City,St Code City,State,Zip Code )n <br /> Oo )(=54 7x95 p <br /> Telephone Telephone ^ <br /> a7gbo C_Cr Rd lrJ <br /> Emergency/Fire No.and Road Name <br /> 2 - ve - !(o C; Lo f- <br /> a <br /> Legal Description(as indicated on tax statement) o �� <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition X Privy Moving Subdivision <br /> Structure Use: <br /> (family home/cabin,garage,additio ,etc.) 0 <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). < o <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. 1t <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, C <br /> river or stream,if applicable. 2 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by O <br /> the owner. <br /> 71 a rn <br /> s <br /> PLOT PLAN Z Q rs ,• �..) o S <br /> De < k <br /> a �i m <br /> o <br /> ) o Xa e <br /> T <br /> Fir <br /> o <br /> o <br /> � � } <br /> E`�cs�r y <br /> Iv) r��S 1� n <br /> o <br /> 0 <br /> j N <br /> d <br /> I�C' <br /> O m .'—mm9RW <br /> v '<_'• mcwo�3 <br /> oo O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c; ? 'm . <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ; m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ii y! N C <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 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 so- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have �`t <br /> access to the above described premises at any reasonable time for the purpose of inspection. i O..v <br /> m � � <br /> �QQN ONF: <br /> SIGN HERE <br /> N O; <br /> (sig tur of owner or I ing contractor) (date) ` o i <br /> ONING ADMINISTRATOR <br /> �inw�in' w _n <br /> N N O N <br /> V T TN O <br /> TOWNSHIP PER ITS MAY BE REQUIRED $SSS S rmii <br />