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UI t l C l i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> y <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 a <br /> tions yf the State of Wisconsin. <br /> �� 111oFn �161T1�`� '��r?l I Jr a <br /> 0 <br /> OWNER(Please Print) Contractor or Su eyor or Ag t F <br /> o � <br /> r d <br /> m <br /> Address Address <br /> D(aU-6n P/al lr'��l���^� <br /> City,State,Zip Code City, State, Zip Code <br /> Telephone Telephone f/' <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for. `» o q <br /> New Building Sanitary Filling/Grading Camping Unit w <br /> Z <br /> J1( <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: P -Oo <br /> (family home/cabin, garage,type of addition,etc.) <br /> 3 <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. o <br /> 3 <br /> PLOT PLAN 0 N <br /> Z c <br /> m a <br /> �p C0Y1 <br /> I <br /> o <br /> 0 <br /> l— <br /> v <br /> y � <br /> z <br /> D <br /> MCO v Ch r- DDW9 <br /> m c .m m m a c <br /> n rr<CL� > 009.= <br /> � ma5�c' 3 <br /> m <br /> Z <br /> Nn: A <br /> i m <br /> : <br /> M <br /> O <br /> of C <br /> o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E E y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o mo <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- 1i <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 /> m <br /> m <br /> H <br /> SIGN HERE 'I �^ <br /> (sig�renof�owwner or uilding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> � T <br /> I V N O N p- m <br /> TOWNSHIP PERMITS MAY BE REQUIRED n a g g o o N <br /> 0000 oog fm/1 <br />