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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m ' o c <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> w <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �+ <br /> Q <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 n O <br /> tions of the State of Wisconsin.. _ n <br /> fie 11 rE C1e /'/4f-S44 �� y <br /> c <br /> OWNER(Please Print) Contractor or Surveyor or Agent n F <br /> 13/ <br /> Addr7 Address <br /> h. ti <br /> a/ 1 p <br /> City,Sttee,Z11i Code6;;? _ City, State,Zip Code <br /> 7 <br /> Telephone Telephone M <br /> Emergency/Fire No. and Road Name fA <br /> a9 .z ? s 77,f j i i of -S-cC' e <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: 0 0 <br /> F <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision <br /> v T <br /> Structure Use: a 3 <br /> (family home/cabin, garage, type of addition, etc.) m <br /> z <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). o <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. n <br /> 0 <br /> 3 <br /> PLOT PLANMi <br /> (�'0l17�07I pmOde— 8'lr6 Z c <br /> Al pz V-4 No r{ <br /> -- - - -- — - <br /> Ole r <br /> 64,7�_ lXk AWOL? <br /> 0 0 <br /> o <br /> 0 O <br /> S <br /> � � o <br /> r <br /> O <br /> r <br /> 0.v <br /> LIC <br /> a5 <br /> aR� <br /> Qj M my En r- DDrD -0 <br /> -j m c .mm nnc <br /> � � m nom '—nm ani <br /> p1 � 00Q <br /> / S 11741Qmy S yfA M <br /> 670Y" m <br /> euJer— <br /> ooE <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o :n' <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 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 a permit. :ma <br /> further accept all liability which maybe 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 remises at an reasonable time for the purpose of inspection. :M <br /> jV <br /> m hz <br /> SIGN HERE :3 <br /> 3:ob Fy <br /> (swnie �ing contractor) (date) <br /> ZONING ADMINISTRATOR <br /> E $ E o <br /> u :nf <br /> XiT <br /> iJN ON PO <br /> TOWNSHIP PERMITS MAY BE REQUIRED �R m <br /> 000000� fA <br />