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iI <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 0 <br /> TOTHE 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- m `m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. <br /> rn m <br /> y � <br /> C <br /> a 0 <br /> OWNER(PI se Print) Contractor or Surveyor or Agent F <br /> o = <br /> m � <br /> m <br /> Adqess <br /> .4 T(1 �, �� Address <br /> (2.� VVU <br /> City,Sthe,Zip Code City, State, Zip Code <br /> i <br /> Telephone <br /> Telephone <br /> P -\ <br /> Emergency/Fire No. and Road Name - <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m .�.' <br /> r <br /> Addition T- Privy Moving Subdivision o ° <br /> v <br /> Structure Use: o ° <br /> (family h me/cabin, garage,type of addition, etc.) <br /> rr ee.' a <br /> Directions for plot plan drawing: <br /> l I� <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North(N). n 1 <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). XJ <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. ( f� <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. a (77 <br /> 3 <br /> PLOT PLAN P <br /> � vn <br /> a\ <br /> 5 <br /> 0 <br /> DOL GhPC� GQJ)N16 <br /> I l <br /> r n N <br /> v ' n <br /> 0 <br /> N <br /> 0 <br /> 0 <br /> N � <br /> n <br /> Z <br /> I � <br /> G <br /> m ca <br /> m m m a C� <br /> 0 ca< = m m a E. m <br /> m a� °-'am 0 <br /> aa � <br /> c' co� 3 <br /> m' `� m ° m) <br /> om <br /> 0 [ 1 <br /> wi m <br /> «� m <br /> o ' O <br /> o o 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 informa. o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I : a <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. lagree to permit county offic Is charged with administering county ordinances or other authorized person to have <br /> access to the above described premis at any reasonable time for the purpose of inspection. <br /> T <br /> m <br /> _ m <br /> SIGN HERE <br /> (sign\ �reof own uil,/d�yrJg contractor) (date) o! o <br /> ZONING ADMINISTRATOR hJJ LL ' L-fln�) <br /> o: <br /> to T <br /> N N O N N m <br /> U•Ut fT tT00(T <br /> TOWNSHIP PERMITS MAY BE REQUIRED S S S S S S S <br /> Mm <br />