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1 X00 <br /> At County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator / o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> v <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. a <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tionsLA <br /> ,of�th 'State of Wisconsin. o <br /> CI�K1 Ei12 (1 a C; 0 <br /> OWNER(Please Print) Contractor or Surveyor or Agent ., <br /> STEd� Print) <br /> leVie <br /> Addresps Address �" I <br /> �O l� <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit m .`.c <br /> Addition Privy Moving Subdivision o <br /> Structure Use: !� �1 zwPal'd(' <br /> (family home/cabin, garage,type of addition, etc.) <br /> Directions for plot plan drawing: f <br /> < f\ <br /> 1.Show the location and size of all existing buildings (EB)and all new buildings(NB) and indicate North (N). y?.. <br /> 2. Show the location of the well (W), septic tank(ST),and drainfield (DF). 0l <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. r " I <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 r <br /> PLOT PLAN 3 <br /> 3 <br /> Z c <br /> o <br /> 5 <br /> N <br /> O <br /> I \ o <br /> 1 <br /> a <br /> SEP 5 10 121 IF <br /> o <br /> '- r1 <br /> � n <br /> a`� J o an <br /> y W o ��' <br /> Z o. ° Z . 1 <br /> • ° ' I rn S <br /> y-S0 <br /> o: o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- — c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue at permit. I i : P <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 pprmit county officials charged with administering county ordinances or other authorized person to have <br /> access to the abov#Pesgobed pr isere sonable time for the purpose of inspection. <br /> - <br /> m <br /> fn <br /> SIGN HERE 1 <br /> ( ' i r f o or building contra tor) <br /> ZONING ADMINISTRATOR _ <br /> TOWNSHIP PERMIT S MAY BE REQUIRED ) �� <br /> { o00 00� <br /> v <br />