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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m o <br /> TO THE ZONING 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 m m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. H m <br /> VIOLET ° <br /> a <br /> OWNER (Please Print) Contractor or Surveyor or Agent 'o <br /> L n rJ t-K. <br /> Address Address <br /> bu , 54830 <br /> City, State, Zip Cj6dd City,State,Zip Code <br /> -115 - ASCI n O <br /> Telephone nTelephone <br /> 5 <br /> �98 LONG LK -Rd _ <br /> Emergency/Fire No. and Road Name / <br /> Legal Description (as indicated on tax statement) `J 1 <br /> � o <br /> Permit(s)Applied for: 0 C. <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit (1 <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage <br /> Structure Use: C? 7(f <br /> / /` a y + W6E o <br /> (family home/cabin, garage, 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). 3 <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within P <br /> 300 ft. Z n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m m <br /> to 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 w <br /> dated by the owner. fn <br /> PLOT PLAN <br /> Sem ktac_h-eon 69P <br /> m <br /> � <br /> 0 <br /> N <br /> o <br /> o � <br /> w <br /> I0 <br /> Z <br /> r <br /> f <br /> A O c m 0 a F nml <br /> M <br /> o < `- u o O 3 <br /> 9 F 0 TZ : i <br /> - N` [ m <br /> 8 o M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 75 m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m 8 <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 /> 0 , o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g m <br /> / m m <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR JImpvY �q(q H. E <br /> 1M N ONHIe (dl T <br /> TOWNSHIP PERMITS MAY BE REQUIRED to Ut N N (n O O O m <br /> 8 $ 8 $ 8888vmi <br />