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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m ' a o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <br /> N <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 71 m <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 /> do of the State of Wi consi n. <br /> r w m <br /> a F <br /> OWNER( lease riot) Contractor or Surveyor or Agent o � <br /> Ad ss Address Q <br /> CityState,Zip de City,State,Zip Code <br /> Gia - sW, -15 <br /> Telephone �— Telephone <br /> Emergency/Fire No. and Road Name <br /> J <br /> Legal Description (as indicated on tax statement) g <br /> Permit(s)Applied for: 2 0 <br /> ct <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> Addition Privy Moving Subdivision o <br /> Structure Use: <br /> 1 I i n� SAl�17-Pka 1 <br /> Z O <br /> a a <br /> (family home/cabin, garage,type o addition,etc.) <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 <br /> n <br /> the owner. o <br /> 3 <br /> PLOT PLAN o m <br /> Z c <br /> o c <br /> n <br /> oCA_ <br /> << �� <br /> Lj <br /> ? <br /> 0 <br /> O <br /> O <br /> _N . <br /> a <br /> I Z <br /> 0hN <br /> O < N N O J <br /> S. O J m <br /> V O = <br /> CO y <br /> m <br /> s : <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- $ 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 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 pr mises at any reasonable time for the purpose of inspection. <br /> N <br /> SIGN HERE <br /> ( re of owner or buil ing contractor) (date) " ` N <br /> ZONING ADMINISTRATOR [ �) 6r <br /> pn <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />