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oR ( Orf- <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> z <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 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tion the State of 'sco sin. <br /> N w <br /> N v <br /> N O <br /> OWN leas Print Contractor or Surveyor or Agent n E <br /> pis �pAier � a o <br /> w � <br /> m <br /> Addr*sl Address <br /> Gln 77 �Co� <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> 1 <br /> EmergencylFire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for ° O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m ,�-- <br /> r <br /> Addition Privy Moving Subdivision o <br /> Q40Structure Use: o a3 <br /> (family home/cabin, garage, type of addition, etc.) 0 <br /> Directions for plot plan drawing: CM <br /> n 1 <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). 9j r <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. o / <br /> 3 / <br /> PLOT PLAN Y/ C <br /> N n 1 <br /> I = <br /> i <br /> G <br /> a. <br /> d <br /> s 0 <br /> w <br /> s <br /> 0 <br /> i <br /> 0 <br /> N � <br /> / Z <br /> / I <br /> � G <br /> d) 0/ D D a m m enc <br /> n Cr Oa- m <br /> m nom - m =a70 <br /> m <br /> m'[ 030= 3 <br /> 1�o -4-o �j— o <br /> �t qORTH -7b?I nE �� �� Oy\ z <br /> m <br /> o C <br /> o l <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ET: <br /> _ : y <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 : 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 Picials charged with administering county ordinances or other authorized person to have <br /> access to th abov described prerises at any reasonable time for the purpose of inspection. <br /> m <br /> m [ <br /> SIGN HERE <br /> i nature of&Vner <br /> nor b,uuildin�g.`contractor) (date) <br /> ZONING ADMINISTRATOR 6f <br /> 'i <br /> l o T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N ooh m <br /> 0 o caoo <br /> 0 0 ooM <br />