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:' " C/01 /Y-), <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w -MV o 0 <br /> 2. <br /> APPLICATION FOR — LAND USE — PERMITS d 3. <br /> 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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions the State of Wisconsjy� = o <br /> e».f In r'C o <br /> OWNER(Please Print) Contractor or Surveyor or Agent �- 0* <br /> 7 2 2 S he /q Irc d <br /> Address Address g <br /> l'rn � r�ut (I � fA SS03� J <br /> City,State,Zip Code City,State,Zip Code <br /> 4/;�. - yac - YY2 � <br /> Telephone Telephone 1 <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 0 <br /> N <br /> Addition Privy Moving Subdivision g <br /> s <br /> C C/l� v v <br /> Z o <br /> Structure Use: ° <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). r- <br /> 2. <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, 0 <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 0 O <br /> the owner. o <br /> 1Ia N <br /> PLOT PLAN Z a <br /> 3 c m - N_ <br /> wl <br /> m <br /> N <br /> W 0 <br /> 0 <br /> J <br /> c � <br /> N Ir <br /> r <br /> I z <br /> ft H <br /> 70 c a <br /> 0 > > � =_.m <br /> m a� a77 <br /> : d <br /> N . <br /> OO : <br /> O <br /> : m <br /> O <br /> Si m C <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 informs- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 desc d premises at any reasonable time for the purpose of inspection. E O o <br /> 3 <br /> a <br /> SIGN HERE <br /> (signs of owneror wilding^c_ontractor) (date) o w g <br /> ZONING ADMINISTRATOR � �� �1)1 <br /> rA in`�:n. Fnw-I <br /> TOWNSHIP PERMITS MAY BE REQUIRED 888N $y <br /> TN T O O <br />