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Burnett County Office of Zoning Administrator m ' o 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 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 n �� <br /> tions of the State of Wisconsin. m o <br /> Ikk �/` a4 Selma C - o <br /> OWNER(Please Print) / Contractor or Surveyor or Agent o A <br /> c 2 d 1� e6STr ° <br /> Address � Address i <br /> City,State,Zip Code City,State,Zip Code K) <br /> OCi <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> Privy Subdivision 0 <br /> r <br /> q \ 8 0 <br /> Structure Use: /\ �( �� -- � v <br /> (family omelcabin arage, addition,etc.) o v <br /> 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(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 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. O <br /> Provide legaldescription on a side o is form) as on ax statement. 3 <br /> PLOT PLAN <br /> 'R <br /> Z c <br /> o n <br /> 31 �-, <br /> 9. i v <br /> N <br /> _ i om <br /> O <br /> �� <br /> S 1 / ■ `- Z <br /> xKTl Z <br /> t <br /> J <br /> 7J mnnM. <br /> = <br /> a rDDc m <br /> m m <br /> ? - '0mn <br /> o Z <br /> of S3� leu-( � ' ' <br /> �: � , m <br /> o c C <br /> I declare that this application (incl 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 an accompanyingschedule and I further declare that I recognize that �v n ' O <br /> PP 9 Y ) 9 <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 ; <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 /> T <br /> N <br /> SIGN HERE t C•. �,,'L ✓ Vu,. — ��, -J z� �' <br /> (signal owner or ding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PER ITS MAY BE REQUIREDnP NNO <br /> tPNU(TO N <br /> 0 0 0 0 0 O <br /> 0 0 0 0 0 O <br />