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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v 0 0 <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 <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 a <br /> tions of the State of Wisconsin. " o <br /> �11f1 J Fite . IF C-4 )i `__: f <br /> D o <br /> OW (Please Print) Contr c or or Surveyor or Agent n F <br /> \� qD w , sry,n�l (mak � d v� Z <br /> ,-, 1_ `(� 1f I C � � <br /> C/ \VCCIG 0 .Y�" 1pG �p �ss Addr��l.l � <br /> '\ <br /> City, State,Zip tode City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) 0 o <br /> Permit(s)Applied for: 2 G> <br /> New Building Sanitary Filling/Grading Camping Unit d 0 <br /> Addition Privy Moving Subdivision $ o <br /> v <br /> Structure Use: o <br /> (family home/cabin, garage,type of addition,etc.) m (JJ <br /> Cd 7L <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 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 /> 3 <br /> PLOT PLAN '9 Cn <br /> Z c <br /> 0 0• <br /> O o <br /> I_ N <br /> ^ O <br /> U' <br /> U' <br /> A <br /> _QL <br /> A <br /> O O <br /> 0 J <br /> O 1,n <br /> � VI <br /> 0 <br /> Z <br /> M cmm as <br /> M. a <br /> n o-< JJ 0a-. m <br /> N `2 ur O J f0 <br /> LA c • O <br /> b i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O o E .: o a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- Ld -^E ' 'o E E m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. N <br /> am : <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I m 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 county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. hh <br /> N <br /> SIGN HERE `• �' lo' <br /> tea : Ov <br /> (si t e of owner ilding contractor) (date) o ? n o <br /> ZONING ADMINISTRATOR <br /> DN: O: is W <br /> TOWNSHIP PERMITS MAY BE REQUIRED Oo' o oo m <br /> 0 0 oo fn <br />