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1 C C� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> w 0 <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 Bur- m `m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of,Wisconsin. <br /> Gary � , /cdfr c <br /> N v <br /> N Q <br /> OWNER(Please Print)) p Contractor or Surveyor or Agent <br /> FlJn £ <br /> � O J06 � dhlfe /fD+ m <br /> Address /-' Address m <br /> City,State,Zip Code City, State,Zip Code I <br /> d� 6 -cher <br /> Telephone TelephoneEms roency/ re_W"g <br /> \ <br /> d Name <br /> icated on tax statement) }J--�� <br /> Permit(s)Applied for: <br /> \b <br /> 0 1 <br /> New Building Sanitary Filling/Grading Camping Unit .: <br /> m <br /> Addition Privy Moving Subdivision g o <br /> Ct L) %• �/ k� A o° <br /> Z <br /> Structure Use: v <br /> (family home/cabin, garage, addition,etc.) <br /> . Show the location an size 0 all existing buildings(EB)and all new buildings(NB)and indicate North (N). o <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, C <br /> river or stream, if applicable. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by O o <br /> the owner. <br /> on 3 m <br /> PLOT PLAN � Z a <br /> o n <br /> See A-tc P�-r Pim C y <br /> 10 <br /> m <br /> W <br /> pw�0 _ro be #Jo "o"-•c. 4 <br /> Nc ro4tl� allay - : Cha <br /> o <br /> _Iv <br /> Z <br /> I p <br /> r <br /> 00 ca <br /> NNm n Ra E.m <br /> o c< > > oa— m <br /> o z° <br /> oM"c0 � <br /> rn �Zmm <br /> 0 o: fDZ i <br /> Mcn 9 <br /> m <br /> c�c' O <br /> nom : C <br /> 1 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 accuracyof all informs- : 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. I <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 t0 have <br /> access to the above described premises at any reasonable time for the purpose of inspection. T w^0 <br /> R UNF: <br /> "64", <br /> SIGN HERE <br /> m o; <br /> (si ure of owner ilding contractor) (date) <br /> o C : <br /> ZONING ADMINISTRATOR <br /> � <br /> t/ NNOoi AN <br /> T <br /> TOWNSHIP PER TS Ny <br />