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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> � y <br /> 0 <br /> TO THE Z"7NING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. <br /> N � <br /> O <br /> OWNER(P^as/g Print Contractor or Surveyor or Agent <br /> /K 2 o m <br /> m <br /> A ss Address <br /> City,S� tate,Zip Code City, State,Zip Code t ^ <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: 0 > <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> m 0 <br /> Addition Priv Moving Subdivision 0 ° <br /> DNL�jv <br /> Structure Use: ° v <br /> (family ho elcabin, garage, type of addition, etc.) n , 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). <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 cf <br /> the owner. O - <br /> 3 <br /> 'R <br /> PLOT PLAN Z c <br /> 0 <br /> 1 <br /> U) <br /> n <br /> 0 <br /> I� <br /> N y, <br /> 0 <br /> I` <br /> o � <br /> 1 <br /> Z <br /> ILD <br /> I <br /> p <br /> m c o to N c m <br /> O a n c <br /> n <br /> m man <br /> T.: O O <br /> O 0 : '2 ; —1 <br /> Cn <br /> m <br /> c 0 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 informa- c G <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 issuea ermit. I : a <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing inpthis ap- V1; <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. r [ <br /> A <br /> m <br /> SIGN HERE <br /> (si at t re of owner or Ing contractor) (date) o <br /> o: o <br /> ZONING ADMINISTRATORL j �, T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N ooh m <br /> o� on ooS Cl) <br />