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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W 'a 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> r � _ a <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 m <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 d <br /> �^ o <br /> OWNES,(Please PriXt7r,/�� � �., Contractor or Surveyor or Agent o <br /> st <br /> Address Address I <br /> City,$t�t/e,,Zip C;q(le „—� City, State,Zip Code I <br /> Telephone - Telephone Olh <br /> Emergency/Fire No.and Road Name P <br /> Legal Description (as indicated on tax statement) <br /> Permits)Applied for: G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit y »' <br /> r <br /> Addition Privy Moving- Subdivision o <br /> Structure Use: o ° <br /> (family home/cadn, garage,typ f addition,etc.) } <br /> w <br /> Directions for plot plan drawing: 0 <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). U <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. "-O <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN <br /> Z c <br /> 0 0 <br /> n <br /> w <br /> io 0 <br /> �1 <br /> U <br /> W <br /> I <br /> C <br /> C Cn <br /> 0 <br /> O <br /> 0 <br /> R. <br /> a� <br /> 0 <br /> N � <br /> CZ <br /> � <br /> N N 0 a Cm m <br /> M a <br /> 0 a< > > 0a-. m <br /> M c, -'am = <br /> g 5' °' cHo� 3 <br /> y' .Z m 0 ra <br /> fA: ^ <br /> i.0 <br /> N �^: <br /> moo: :no C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: n a y <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 o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- :m C <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I i n <br /> further accept all liability which may be a result of the Count of Burnett relying on this information I am rovidin in this a '^ <br /> P Y Y Y Yy 9 P s P' (� i <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have : �o; <br /> access to the above described remises at an reasonable time for the purpose of inspection. <br /> :v; <br /> P Y P P P <br /> m �['�• YJ N; <br /> /a/90 Pic)SIGN HERE T� m :o: <br /> (sign u of o er o 0xilding contractor) (date) ov <br /> tD <br /> ZONING ADMINISTRATbOR 0 <br /> nii au T <br /> � <br /> TOWNSHIP PERMITS MAY BE REQUIRED �� m <br /> 0000� fA <br />