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Qn COmf <br /> Burnett-County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> N <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 a <br /> tions of the State of Wisconsin. <br /> O <br /> N d <br /> Tye c <br /> OWNER(Please Print) Contractor or Surveyor or Agent o F <br /> Addre s Address <br /> r�hcft, GGi. ,fs�df� <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> �/b b4KE �Q <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> m' <br /> Permit(s)Applied for: 0 G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit < <br /> N <br /> AdditionPrivy Moving Subdivision o <br /> _14) <br /> p� v <br /> Structure Use: I �1 0 <br /> (family homelcabin, garage, type of addition, etc.) m <br /> a <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 /> the owner. O <br /> 0 <br /> PLOT PLAN o <br /> Z c <br /> o 0 <br /> o <br /> I = <br /> � r2 <br /> � C s <br /> 9 � <br /> 0 <br /> o <br /> = r� <br /> o " 1 <br /> N � <br /> !V Z <br /> l � <br /> 0 con <br /> 0 0ncmm <br /> o a 0 a M <br /> 0 = 0 n= <br /> C ^ 0 0 <br /> pup-ml 74 <br /> q 0C <br /> _- ! C <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 informs- �� 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. 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 cou y officials charged with administering county ordinances or other authorized person to have <br /> access to the above de sc ' remises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (signat of owner or ild!�rtAg/cIo'n1tractor) (date) o ; o <br /> ZONING ADMINISTRATOR �_ t I/I fiC� 7//7/V <br /> ON <br /> ven T <br /> TOWNSHIP PERMITS MAY BE REQUIRED ��� m <br /> Vo8$$ tn <br />