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, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office on1 gCr'Administr or d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <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- 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. m o •6 <br /> !h4 C m '"' <br /> " o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o- f <br /> a � ois Loeue P,ut � Rd R <br /> (�t <br /> Address, Address <br /> p <br /> City,State,Zip Code City,State,Zip Code 1 t\ <br /> r a <br /> Telephone Telephone <br /> 1 <br /> EmergencylFire No. and Road Name <br /> Legal Description (as indicated on tax statement) n <br /> Permits)Applied for: 0 O '0 <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit H <br /> r <br /> Addition Privy Moving Subdivision o <br /> v , <br /> Structure Use: o <br /> (family homelcabin, garage, type of addition, etc.) r` 1 <br /> N <br /> Directions for plot plan drawing: J <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). C (J <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. ^'—0 6 <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- O <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 ,.O <br /> the owner. V)0 0 <br /> 3 <br /> PLOT PLAN a w <br /> Z � a <br /> P y <br /> _ <br /> S <br /> 9' <br /> o <br /> N <br /> 0 <br /> r <br /> IT <br /> lko <br /> Z <br /> D <br /> mc�m m 0 a c t <br /> m a� D =am nag <br /> a ^c o o� 3 <br /> N 2 N O =m <br /> A <br /> - � m <br /> LA o <br /> C <br /> jz <br /> ` O <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= o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- .0 G <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 premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE s LV ` Lo <br /> (signature er of dcont (date) o <br /> ZONING ADMINISTRATOR ����� 0 $� c <br /> C) _ <br /> T0SHIP PERMITS MAY BE REQUIRED P opu, m <br /> oog <br /> 6oofA <br />