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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 0 C m I <br /> Office of Zoning Adminisstt rator w CD 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS <br /> v <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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions a <br /> tions of the State of Wisconsin. _ <br /> 0 <br /> OWNER(Please Print) <br /> Contractor or Surveyor or Agent <br /> Address Addre s t } <br /> +Q�Ty_h W1SG t <br /> City, tate,Zito <br /> Code City, State,Zip Code <br /> Telephone © R�3 `_ <br /> Telephone i <br /> Emergency/Fire No. and Road Name <br /> ZZ <br /> Legal Description (as indicated on tax statement) ) /-� •-�/• <br /> M ,� / / % 211 oC(p / br o <br /> Permit(s)Applied for: xb G3 4A i!— CD <br /> - <br /> New Building Sanitary 1/ 1 t Fillin /Gra7din /[ o' <br /> 9 g Camping Unit <br /> Addition Privy o <br /> ,�/r Moving Subdivision S r <br /> Structure Use: ac t G'� /1�!' s �� �•..L�Q --�1� 130fZA/v�� do. z T o <br /> o <br /> (family home/cabin, garage, type of addition,etc.) <br /> m <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). t <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. <br /> n <br /> PLOT PLAN 3 <br /> c <br /> Z <br /> o a <br /> A <br /> m <br /> 71 <br /> ``OP Z <br /> 41D >G <br /> .6 407 <br /> m c-Vw w >acco <br /> m 0-'< - C a-_ m <br /> EL- 70 <br /> Z � C O cc 3 <br /> 0 o: <br /> I declare that this application(including an accompanyingschedule has been examined by me and to the best of my knowl- o � C <br /> PP (� 9 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- vi G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I `? ' D <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 /> W <br /> CD <br /> SIGN HERE <br /> (s <br /> ,!gKa ure of owner ilding contractor) (date) o o <br /> ZONING A INISTRATOR d b: <br /> O: <br /> TOWNSHIP PER ITS MAY BE REQUIRED N N O N m <br /> ���� o m <br /> 0000o fR <br />