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. 1 <br /> l , <br /> Burnet" County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 F <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- N M <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 /> Al bc'J(�T �1_ 1 ur�Et3csvJ w w <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o 3E <br /> to 4 NLN ICM F�-r d n <br /> A <br /> ress Address �• <br /> City, State,Zip Code City,State,Zip Code I <br /> 7�� ''yq - al��i/`i I C <br /> Telephone Telephone d <br /> 6 �/� N,�u,a., 7,19Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 < <br /> Addition Privy Moving Subdivision o <br /> M <br /> Structure Us - 0 0 o <br /> ��� (familyhome/cabin, garage, type of ddition,etc.) <br /> Directions for plot plan drawing: / I ( *' / U <br /> 1.Show the location and size of all exi ting build (EB)and all new buildings(NB)and ndicate 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. n <br /> 0 <br /> 3 <br /> PLOT PLAN -- P <br /> / N <br /> Z c <br /> o n <br /> p� qy <br /> Nuke- n Its 1 ! �/U O'�F FX1Orl grass /fear. <br /> 0 W a <br /> u� <br /> LTI <br /> J n <br /> o <br /> O <br /> o IlN <br /> 0 iA <br /> o V1 <br /> i0 <br /> 6 <br /> 3 Z <br /> � R <br /> 0 C6 r- <br /> 0 cam <br /> crn o� ; <br /> o <br /> Z o <br /> 0 <br /> 0 mN N: m <br /> }-oD <br /> O: Y0 O: <br /> \O O; C <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 informs- <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 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- �-: v> <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> a:v: <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> / r_ ho <br /> SIGN HEREC� <br /> (sign re owner or Ing contractor) (date) tJ E o <br /> ZONING ADMINISTRATOR <br /> :nn .n <br /> TOWNSHIP PERMITS MAY BE REQUIRED �NNo v f Pm <br /> 4 uvpuo._W <br /> gogogg�Vf <br />