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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator (00 o z <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m ° S- <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c n S; <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n r <br /> tions of the State of Wisconsin. - r <br /> OWNER(Please Print) Contractor or Surveyor or Agent �' F <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code J" <br /> Telephone </� _ ;f,/G Telephone <br /> M <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition _ Moving o - <br /> Sanitary Camping Unit O <br /> Privy Subdivision o ° N <br /> J V <br /> N r <br /> 7 O O <br /> Structure Use: gra - /Cc ✓c' t /�/�/J i r h/ /� <br /> (family home/cabin, garage,addition,etc.) 0 z S <br /> 0 <br /> a <br /> m <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). <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. o <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 a signed and dated by <br /> the owner. 6. Provide legal land description. i <br /> PLOT PLAN 3 <br /> a <br /> -- Z c <br /> (� J <br /> O � s <br /> w <br /> t,7 5 r <br /> � O <br /> Or��e <br /> N w <br /> o <br /> JC <br /> I i )\ <br /> I/ k T-) o <br /> D <br /> 1i •f <br /> 9Qa t <br /> tv <br /> O / <br /> EL <br /> O O �j <br /> Co: � ; D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all W i M <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that ({'�, A m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a Vl o <br /> permit. I further accept all liability which may be a result of the County of Burnett relying on this information I am providing [ <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE ��' ` �— /•J - J i d' <br /> r ( ig lure of own r building �ontractor) (date) <br /> ZONING ADMINISTRATOR I o o <br /> 11 w T <br /> TOWNSHIP PERMITS MAY BE REQUIRED o" N 0 N)op N m <br /> 00000�fmA <br />