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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator / w A a o <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 Bun <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 W14onsi m 0( � S M i k se / = n <br /> © <br /> 0 <br /> OWNER( se Print) p / ../L Contractor or Surveyor or Agent o 3E <br /> L SOPlea <br /> Address �// Address <br /> C7 ' <br /> felt c A k- !S7_V <br /> City,State,Zip Code City,State,Zip Code I <br /> lP/d ��5/b • 7y/l (-. <br /> Telephone Telephone <br /> vn <br /> Emergency/Fire No. and Road Namer�1 <br /> Legal Description (as indicated on tax statement) o 1�. <br /> Permit(s)Applied for: L ) <br /> o <br /> New Building Sanitary I Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision o <br /> 71 <br /> CJzdrd � � SA �IlJ9zt � <br /> Structure Use: Z � <br /> 0 <br /> (family home/cabin, garage,type of addition, sic.) <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). o <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 feel of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to ordiJt <br /> - <br /> nary high water mark of 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 dated by <br /> the owner. O <br /> 0 <br /> 3 <br /> PLOT PLAN o <br /> _ Z N <br /> c <br /> o n <br /> o � <br /> 1 ' <br /> J <br /> 1 <br /> n <br /> 7S <br /> &I <br /> ti <br /> N � <br /> 0 Z <br /> Ari <br /> m (nww o ncm <br /> 0 Q� > > oo.—' m <br /> m n� - am ^;nA <br /> a <: 0 <br /> L H O J C <br /> D <br /> 0 . <br /> C : Q <br /> C) o C <br /> I declare that this application(including any accompanying schedule)has beenxamined by me and to the best of my knowl C7 0 i i y <br /> edge and belief it is true,correct and complete.I acknowledge that I am respons ble for the detail and accuracy of all informa- J=E $ m <br /> tion contained in this application(including any accompanying schedule)and I f rther 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 i n <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 /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE . <br /> (sign tur of owner o ding contractor) (date) o b" <br /> ZONING ADMINISTRATOR o o <br /> n T <br /> CJ���� ooNm <br /> TOWNSHIP PER ITS MAY BE REQUIRED o$0 0 0 0 o umi <br />