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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zomn '"kr. -.._, )r Cn d -0 -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d 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 <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. w m <br /> 4)22� 0 <br /> OWNS(Please Print) Contractor or Surveyor or Agent n F <br /> 9 U'Flb LcS �c� <br /> Address m <br /> Address LL <br /> IAGIJSLG� � I �. <br /> City,State,Zip Code City,State,Zip Code <br /> 54 y9 3 <br /> Telephone Telephone <br /> 715- 366/439 d <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) p <br /> Permit(s)Applied for: ^ o <br /> New Building Sanitary Filling/Grading Camping Unit ° .`.- <br /> m r <br /> Addition Privy Moving Subdivision g ° <br /> v <br /> 5cn«n PoR� omN t Z ° <br /> Structure Use: o v <br /> (family home/cabin,garage,addition,etc.) <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). 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. 11 <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. 21 <br /> 5. If,separate plans are submitted by an architect,engineer,but der,contractor,etc.,the plans must be signed and dated by Q o <br /> the owner. / 0 A� <br /> 11v m <br /> PLOT PLAN 'Z C <br /> h005-e <br /> ` N <br /> 1 <br /> C f, <br /> 71 . <br /> N <br /> W cLl� <br /> W <br /> s <br /> m <br /> o <br /> w I <br /> Z <br /> / S <br /> m n� '—nm aa9 <br /> 00 =0 _ <br /> Z o i 1 <br /> mil�li A <br /> — ' i rn <br /> N8 dam: c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. 0 ; A <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- = E ? 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 w u, <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. i 0~ <br /> SIGN HERE ' E v" $ <br /> (sia u e owner r ilding contractor) (date) p: <br /> ZONING ADMINISTRATOR <br /> inHHin in in gAM <br /> N N O N++ <br /> TOWNSHIP PERMITS MAY BE REQUIRED `n v,p v,o o g m <br /> '088888g <br />