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M- /�)X/ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator En 3 f o <br /> APPLICATION FOR — LAND USE — PERMITS d o <br /> TO THEZONING 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 '� c <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 0. <br /> 0 <br /> regulations of the State of Wisconsin. H <br /> al J k6& <br /> 0 NE Pleas Print) Comrador or Surveyor or Agent C�y <br /> A dress Address <br /> Ci y, ate„Zip C aCity, State, Zip Code <br /> Telephone Telephone S <br /> Emerge cy/ 'i, No, ,ryd-�oa�,yam T , `I X/ /,, I, r I <br /> 10 <br /> LeLarDescription (as Indicated on tax statemen <br /> 0 <br /> Permit(s) Applied for: <br /> N 0 <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit n <br /> Z o <br /> 0 <br /> Accessory Buildin Sanitary X-- Privy Subdivision _ <br /> Garage1� <br /> Structureuse: 1 )Q `h 4 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 !, <br /> 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 m <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within Z Q <br /> 300 ft. o n <br /> 4. Show dimensions infeat of the following:(a) building to all lot lines,(b)building to center line of road,(c)building N G <br /> to lake, river or stream, if applicable. fA ° <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H I <br /> dated by the owner. m x! z <br /> PLOT PLAN cygT'J) <br /> C ti E� <br /> 0 <br /> 0 <br /> o � <br /> J <br /> o <br /> Z <br /> z <br /> 1 <br /> Do c -� m m D Dn O <br /> �� ''- a m °' m M <br /> 9 N <br /> $ m N C N o � <br /> J ep <br /> Z mm z M <br /> o f �! Ul : p <br /> M <br /> v O C <br /> 8 <br /> mm <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 8 <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.1 agree to permit county officials charged with administering county ordinances or other authorized person to have m g o <br /> access to the above described premises at any reasonabl time for the purpose of inspection. ^ N <br /> A N A <br /> SIGN HERE <br /> See- 9 / l /rte -LO H s <br /> (at at re of owner Iding contractor) (date) o x <br /> g <br /> ZONING ADMINISTRATOR <br /> (AH �6)d1N T <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8 N 8 N 808 0 8 <br /> 9 <br /> (J)' S&Ik <br />