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l <br /> L1✓l, (_it :,'�' ._f , <br /> Burnett Countv 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m -0o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w - <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- <br /> tions of the State of Wisconsin. <br /> T4 mN V �) <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> Address Cu 01,14^ - Address `j <br /> S ooner _ i „ I <br /> City,State,Zi Code City, State,Zip Code <br /> 3s- i/S <br /> Telephone Telephone — <br /> Kas <br /> Emergency/Fire No. and RoaNa^me <br /> Legal Description(as indicated on tax statement) 7 0 <br /> Permit(s)Applied for: jo 0 6 <br /> 0 <br /> New Building Sanitary t. Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision0 o <br /> v <br /> SLwE4i �e ma <br /> Structure Use: 0 <br /> a y homelca , ga e,type of addition,etc.) <br /> IWW0W*6 ft efje I <br /> Show the VOMM lf6h6S�l(t 'MB)and indicate North (N). r ' <br /> 2.Show the location of the well (W),septic tank(ST), and dralnfte1t710P): vJ 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. `J) <br /> lflalldl o N iQ't'.Nties,M building to center line of road,(c)building to ordl- <br /> 01RIalke,river or stream, it applicable. w <br /> 6.I6;y rWpi+larwwietm i ted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> tfltl'tl1 91. o <br /> 0 <br /> 3 <br /> PLOT PLAN <br /> 0 <br /> y <br /> 44"/ �`� <br /> I <br /> c� <br /> CI � <br /> k'o at-&di� o� �S���e a /� <br /> 6(- <br /> A)tAJ G . <br /> m c�md n civ <br /> n c< o 0 o c <br /> fD <br /> c : m <br /> �:• : C <br /> ` � [C:� <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- l,lf <br /> sdge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- ;�ao: m <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 : p <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 /> SIGN HERETIL <br /> (sig ur of owner o contractor)ZONING ADMINIST ORInTOWNSHIP PER ITS MAY BE REQUIRED221�� SSSSS�%n <br /> l <br />