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Burnett County 7418 Co. Rd. K, #182, Siren, w1 54872 Office of Zoning Administrator m 0 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <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 J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 nl <br /> tions of the State of Wisconsin. <br /> N d <br /> GERIQLc V"14W N) C <br /> a �OWNER Print)(Pleas Contractor or Surveyor or Agent <br /> �� <br /> Address`' 1', 1 Address <br /> City,State,Zip Code City,State,Zip Code c)(,) <br /> 1 <br /> Telephone Telephone <br /> I <br /> Permit(s)Applied for: <br /> New Building FillinglGrading <br /> Addition Moving o ,� <br /> Sanitary Camping Unit 0 o <br /> Privy Subdivision 5 ,<.- <br /> m r <br /> 1rJ r �)f�Cl �7nly ° <br /> Structure Use: Lv <br /> (family homelcabin,garage, addition, etc.) o <br /> m I <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). r <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 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. 6. Provide legal land description. n <br /> 0 <br /> PLOT PLAN 3 <br /> p j m <br /> Z a <br /> //^^ 0 a <br /> 7T �r� <br /> y <br /> ai <br /> Jam/ <br /> 1 <br /> W r <br /> `j 0 <br /> O <br /> \ I� <br /> O <br /> O _ <br /> 0 <br /> J Z <br /> Cd I (fYYV�-/, JJ <br /> su n <br /> R� � (dam <br /> � to to r D D W'fl <br /> C� I r ll I 0 a,<c ,= m a n M <br /> N 0 0 0 fl <br /> Z ii Z : 1 <br /> O ' C': <br /> SI <br /> C : Q <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <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 n I <br /> PP ( 9 Y ) t p ; O <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 0 <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> -L m <br /> SIGN HERE 1 rI t7� <br /> (s' nat re ft owne r uilding contractor) (date) <br /> ZONING ADMINISTRATOR o <br /> o: o <br /> m <br /> TOWNSHIP PE ITS MAY BE REQUIRED N N P�O p R P N <br /> � oau,m <br /> 0000000 Vl <br />