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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratoru 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> O <br /> TO,THE ZONING,*DMINISTRATOR: 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- n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> tions of the State of Wisconsin. " p <br /> J <br /> OWNER,(P;tes Print) Contractor or Surveyor or Agent �- 0 <br /> X/iAl tL <br /> AddresslAddress <br /> lr <br /> I <br /> City,St a Zi Code City, State, Zip Code <br /> 7,2 <br /> � - - a <br /> Telephone Telephone I r� <br /> Emergency/Fire No.and Road Name <br /> P i <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> O <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision 0 <br /> v <br /> Structure Use: o g <br /> (family homelc in, garage, typ of addition, etc.) m <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. <br /> 0 <br /> PLOT PLAN 3 <br /> 2 c <br /> O n <br /> N <br /> O <br /> 1 � <br /> W o <br /> J <br /> i <br /> rj <br /> 0 <br /> N � <br /> N Z <br /> D <br /> m c�wiu >nc� � <br /> n a< JG on <br /> — m <br /> J:aMI <br /> a <' "ci'oo33 <br /> Ul `z N O JIG <br /> Z O N 2 <br /> P G : rn: M <br /> N O Y <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: 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- = o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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- <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 /> m <br /> SIGN HERE <br /> (sighr f owner or buildl ontractor) '(date) <br /> b <br /> ZONING ADMINISTRATOR <br /> w -f <br /> TOWNSHIP PERMITS MAY BE REQUIRED n v v o'o m <br /> I gg00000W <br />