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n Co Cc-) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co w o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3• <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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n 0 <br /> tions of the State of Wisconsin. <br /> w w <br /> Joule_ - Jc.�,et Fo�ra�e � <br /> OWNER(Please <br /> �Print) <br /> � p Contractor or Surveyor or Agent <br /> �� a FO <br /> m m <br /> Adress Address <br /> City,State,Zip ode City,State,Zip Code I <br /> Fj�f (o q(a`t D <br /> Telephone Telephone <br /> 'Iq q(o <br /> Emergency/Fire No. and Roa Name <br /> Hts1 r (9-2� $(9��/�[(o AGecs 0249 S /�CC'`F//O <br /> Legal Desfcription (as indicated on tax statement) 5J/,2 �Qu� Z o t <br /> m <br /> Permit(s)Applied for: m <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Peck ele Privy Moving d Subdivision <br /> Structure Use: y-! 1Gn 'neck$ X�� / 4�— D `X/y Z o <br /> (family home/cabin, garage, type of addition, etc.) Ib <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). n <br /> 2. Show the location of the well (W) septic tank(ST), and drainfield(DF). <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�LAN 3 -{- <br /> W \ r P� 4 n (� <br /> rJ I <br /> S � p <br /> DF w <br /> pier <br /> 160 / r� <br /> N <br /> 2y <br /> 0 <br /> BBIrl73I <br /> as <br /> Iz' <br /> 36 �� 4, <br /> t <br /> r <br /> ISO <br /> �a r M COM 0 r- DD ca <br /> 0ac m <br /> E.^. <br /> FL <br /> Pam '-nma <br /> �n a <° 01c0 3 <br /> c Z N `2N 27fO i <br /> p 0 ' <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c o i 0 Ec� <br /> edge and belief it is true,correct and complete.I acknowled a that I am responsible for the detail and accurac of all informs- " a:a <br /> 9 P 9 P Y :w o; m <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 <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. i bill i <br /> m <br /> Pt : <br /> a 5n( i <br /> SIGN HER P iz E <br /> (s' n ure of owne ding contractor) (date ` �m <br /> �? : o <br /> a ; n <br /> ZONING A NISTRATOR L '• i gip ; <br /> i n r <br /> "� iJNON��MM <br /> TOWNSHIP PERMITS MAY BE REQUIRED �m n nu oORIn <br /> 00oo oo rA <br />