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c3n (-cm ( <br /> Burnett County 7410 Co. Rd. K, 11102, Siren, WI 54872 Office of Zoning Administrator m o 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 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 m <br /> (D o <br /> a <br /> OWN R(Pleas P' t) Contractor or Surveyor or Agent o m <br /> �� /1, <br /> Aj/L/ �� Address <br /> / v CSS <br /> City,State,Zip Code City,State,Zip Code ) -� <br /> Telephone Telephone (��^ <br /> Permit(s)Applied for: (�-1 <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary ✓ Camping Unit o <br /> Privy Subdivision w <br /> SQru�Qa� OnCri <br /> Structure Use: Q � <br /> (family me/cabin, arage,addition,etc.) Z 0 <br /> o a <br /> _ m <br /> Directions for plot plan drawing: v_) <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 lake, <br /> 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. 6 Provide legal land description. o <br /> PLOT PLAN v u, <br /> c <br /> Z v <br /> P a <br /> N <br /> r <br /> G �� a <br /> a� e <br /> 6 <br /> 0 <br /> J <br /> N <br /> O <br /> J <br /> O <br /> T (� <br /> (D <br /> Z <br /> O <br /> Z <br /> I � <br /> 0 ' <br /> N 0->>W-0 <br /> m <br /> n EL <br /> LD. a ate - 0 r:aS <br /> mi00oJ3 <br /> Z <br /> 0 1 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 1 o <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all n In <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing n <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> N <br /> SIGN HERE <br /> 119 <br /> tul <br /> contractor) (date) <br /> ZONING ADMINISTRATo � o <br /> OR <br /> N NON +N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 0000000 <br /> 00000 oofn <br />