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C �\ C (-, i1) �' , <br /> Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator ? £ o <br /> APPLICATION FOR - LAND USE - PERMITS - 3. <br /> O r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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- 3 0 (^ <br /> lions <br /> the State of Wisconsin. m y _ <br /> � y <br /> OWNER gle Print Contractor or Surveyor or Agent ^p v! <br /> Addres Address <br /> � �EwI7�71is <br /> City,State,Zip Code T-�'�'—��"l¢11 City,State,Zip Code <br /> Col"1. F -rQ.'� c4� uC' <br /> Telephone ��o —.4-z-i� Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary Camping Unit <br /> Privy Subdivision m <br /> Structure Use:— Z o <br /> (family home/cabin, garage,addition,etc.) o <br /> m <br /> n <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 be signed and dated by <br /> the owner. 6. Provide legal land description. 0 r- <br /> 0 f <br /> PLOT PLAN 3 rn <br /> c <br /> Z a <br /> o n <br /> H <br /> O <br /> I <br /> a <br /> N <br /> i O <br /> 11llp . J <br /> O -� <br /> T'4 14 4 <br /> C <br /> i4 Ggr�y� y T, Z <br /> \ 5 / D <br /> 15 / <br /> 7J m 17 0 0 0 lD <br /> n c<> <br /> -_ n_ S <br /> o N C O J <br /> Z y z w O J <br /> O <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> : <br /> o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all A m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that O <br /> PP ( 9 Y ) 9 pp <br /> this informatio I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a j o <br /> permit.I furthe am <br /> all liability which may be a result of the County of Burnett relying on this information I am providing li ' m <br /> in this applica4i n. I agree to ermit county officials charged with administering county ordinances or other authorized a <br /> person to hav ccess to th bove described premises at any reasonable time for the purpose of inspection. <br /> T <br /> FD N <br /> �1 <br /> SIGN HER g fur of owner orb contractor) (date) o i o <br /> /f o: o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS AY BE REQUIRED NN o N j j <br /> P v,v.cnoo <br /> ` 00000� <br />