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on come , <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'D 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and in <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n O <br /> tions of the State of Wisconsin. o <br /> .Di'c _QeFFi`iy6' �e�� m <br /> OWNER(PleasePrint) Contractor or Surveyor or Agent n E <br /> ��►' moo, d 0 <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone d <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for. y1 <br /> 0 <br /> New Building _ Sanitary Filling/Grading Camping Unit 0 <br /> w <br /> Addition Privy Moving Subdivision <br /> Structure Use: a <br /> (family hometcabin,garage,addition,etc.) 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). ➢ a <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. 1I <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 fake, C k 1 <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 n <br /> 0 <br /> the owner. ; / 0 <br /> Milla U) <br /> PLOT PLAN VV7I Z v <br /> O n <br /> m �, <br /> C �� o <br /> /V, <br /> f ; <br /> C4 4t> <br /> ,r <br /> OF F S�,T�' <br /> ST= .1-0N•W. o �) v <br /> I 6�'��1'Fn' .t.'.NF��vHDXY a <br /> I s•rE Too .0 Aij%F I o <br /> n <br /> J <br /> I s <br /> I z <br /> f <br /> m c o.mmonc <br /> 4 *11FQB � m �� �•nm aii� <br /> o wi Zwom3 <br /> izl U2 i 1 = <br /> q. : —R; <br /> o <br /> 8' mei c <br /> I declare that this application(including any <br /> ppanyi has been examined by me and to the best of my knowl- <br /> edge and belief It is true,correct and complete.I ackhowlgdge that 1 am responsible for the detail and accuracy of all informs- n, m <br /> tion contained in this application(including'^accompanytng.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 iii w v, <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- ; $'P $ <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. O^p <br /> SIGN HERE <br /> (si tur g contractor) (date) (`} o g <br /> ZONING ADMINISTRATOR •'"t �' $' <br /> O NNONy+�+ i n <br /> TOWNSHIP PER ITS MAY BE REQUIRED P o p o m <br /> $8g$888rn <br />