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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> N 0 <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- V� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. <br /> tions of the State of Wisconsin. <br /> 0 <br /> N N <br /> ,Bd FBF i'�t2M rJ t l-� = o <br /> OWNER(Please Print) Contractor or Surveyor or Agent n f <br /> g33O <br /> � 0.►NNoN F4L31v � r <br /> Address Address O <br /> L-JAM b t'A N All ''N IV � <br /> City, State,Z Code ( City,State,Zip Code <br /> Telephone Telephone t <br /> ,,/a L;43 7 s 3 5/3 <br /> EmergencylFire No. and Road Name <br /> g.�v � Sd f?a ,vNe ? Lake j?d '4 <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: Gt <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m .<.- <br /> Addition —4— Privy Moving Subdivision o <br /> v <br /> Structure Use: C %N cao ° <br /> (family hom bi garage, type of addition,etc.) } t <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). 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- <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 /> 0 <br /> 3 <br /> PLOT PLAN 0 c <br /> ,31 A) N e /R — a'`- o4�k C 0 a <br /> t < <br /> .. o <br /> tie Ff � <br /> { I <br /> � m <br /> t � <br /> a <br /> N /� r <br /> r <br /> ; Q E8 Z <br /> Itz <br /> T <br /> a <br /> a <br /> n Q< = = = n . z <br /> PI ps a <. d= y o . 3 <br /> Z 5: zNo � <br /> •----- S d 13a N N e L a iC e 'af -- p ' [ M <br /> m <br /> of 0 ` p <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- $[ 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 <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. <br /> T <br /> ZZZ <br /> N <br /> SIGN HEREin <br /> (si re of owner o ' ding contractor) (date) <br /> K:8 <br /> ZONING ADMINISTRATORTTOWNSHIP PERMITS MAY BE REQUIRED `n U1 p,o�g ami 000 <br />