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X66))T,, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m - o a <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and OF <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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, I I f o <br /> ( /.'r•o ' rYG Lren Q�a �PS Ijk���Pri m <br /> OWNER(P easFe, Print Contractor or Surveyor or Agent n f <br /> 0773 !7 �h{ <br /> Address rr Address <br /> ��PS6�rr- �.)t S�� g5 Z �4✓I`O4ti N kJrS S 10.30 �. • <br /> City,State,Zip Code City,State,Zip Code <br /> Ga. 7yo3 � <br /> Telephone T9 Telephone <br /> Emergency/Fire(Nb. and 7.3Road Nam <br /> --) 77 �4 n�prn� Ir I(r$ <br /> Legal Description(as indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for. <br /> New Building SanitaryFilling/Grading Camping Unit 0 15. <br /> N <br /> Addition Privy Moving Subdivision <br /> � Q� p <br /> Structure Use: moue O � Fws1joGcm4-a g'J { a � z v <br /> p a / <br /> (family hometcabin, garage,addition,etc.) a `� <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. Show the location of the well(W),septic tank(ST), and drainfield (1317. <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 lake, C <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 O <br /> the owner. O <br /> PLOT PLANj- an3 <br /> y o _a <br /> o,J.w Y°` < <br /> �.I C <br /> aN <br /> M <br /> S1' <br /> SRG <br /> t7 <br /> 12 o <br /> ��,•.� /.SPE � Y,'"er� tl,� N <br /> -2 t Pal. hsP� <br /> i <br /> 1 � tAi <br /> --- ?N <br /> Y <br /> (� ff <br /> , <br /> Imu,,,� Syaie•^� � <br /> Q / <br /> 4, 7 'nm nSM <br /> rn <br /> g: <br /> I declare that this application(including an accom an in schedule has been examined b me and to the best of m know!- <br /> PP ( 9 Y P Y 9 ) Y i <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <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- oa <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above de ribed premis a n reasonable time for the purpose of inspection. O p <br /> m m m <br /> SIGN HERE <br /> si u e of 45Wner or bdi contractor) (date) <br /> P o y g <br /> 1 <br /> ZONING ADMINISTRATOR c' <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N m <br /> Sg00000rmA <br />