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C6 com( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z _ o <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 Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. o <br /> OWNE (Please Print) ` ' I Contor or Surveyor-pr Agent a £ <br /> y � / �S(� LIN aci(17 GOi m <br /> Address Addre `� <br /> City, State Zip Codhe, Q��C City,State,Zip Code , <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) p <br /> Permit(s)Applied for: � <br /> C <br /> O <br /> New Building Sanitary Filling/Grading Camping Unit .`.- <br /> N <br /> Addition Privy Moving Subdivision g a <br /> M <br /> Structure Use: o a <br /> (family home/cabin, garage, type of addition, etc.) m <br /> 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). <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 ordi- <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. n <br /> 0 <br /> PLOT PLAN a .F <br /> Z c <br /> e i <br /> Vo <br /> 5 — 0 <br /> t _ <br /> CP <br /> A <br /> In Z o <br /> I <br /> m0a� <br /> 0 <br /> w -1 <br /> .Oi <br /> Z <br /> a <br /> F <br /> 0 a< = 00a-. m <br /> m <br /> =am <br /> a E 0 <br /> Ea <br /> Z N p 7 O <br /> o <br /> J N <br /> gi O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- go 00 ; � <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of allinform a- c 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 o [ <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 /> T <br /> N <br /> SIGN HERE <br /> (sig_n.a�}u r�e,o�f o�wnerp buili ng connxt-ra�cttor) (date) o? � <br /> ZONING ADMINISTRATOR DIY"->�G(��f11 V1�'D \ of E o <br /> w -t <br /> NNOIN N <br /> TOWNSHIP PERMITS MAY BE REQUIRED (T N N O Oa"-O m <br /> N <br /> J0000goofmA <br />