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aft c m <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d _ o 0 <br /> iE <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d 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- 0 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. o <br /> OWNER(Please Print) Contractor or Surveyor or Agent ii £ <br /> (.�,rwl G. y19PoSa/•'�' kCy�%so�v d <br /> A ress/ Address :? <br /> �O 00 �ClS�jery t�-0 <br /> Ilya State,Zip Code City, State,Zip Code <br /> /G'�vs?e +l' WJ'S c 5Y& q 3 <br /> Tgleph9fra_ / ` L—� Telephone % <br /> Egent Fire No. an Road Name <br /> Em 00roAw?x �7 <br /> Legal Description(as indicated on�tax statement) W`ss l D /yc/ <br /> .�E 6� ,�� ••f-,S'G(J v <br /> Permit(s)Applied for: 5 �� �'�' / = o <br /> New Building Sanitary Filling/Grading Camping Unit .`.- <br /> w r r <br /> Addition Privy Moving Subdivision S <br /> _ v //I <br /> Structure Use: Ad?1;9 GJ'L' a�.X.30 z o � V� <br /> (family hometcabin, garage,addition,etc.) Q <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). o <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. <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. X1 <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by C <br /> the owner. <br /> on v U <br /> PLOT PLAN7I z ii <br /> C <br /> w S- <br /> M <br /> N <br /> m <br /> � C <br /> �l sY,yr wy f <br /> I <br /> _ youSr� a6'� dpRn; ,6 <br /> f:ejAk4Y <br /> . aid <br /> � <br /> r , I <br /> I(90 r 1 IEL <br /> m an.wwoaacmWL "en <br /> nn T (^ <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- o` n '• C <br /> PP ( 9 Y ) Y Y o f m m : m <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- . iw g N D <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I '• m v,, <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- i $_P $E <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 /> 3 <br /> SIGN HER <br /> m <br /> (si ur of owner 'ding contractor) (date) <br /> i gi i <br /> ZONING ADMINISTRATOR <br /> iw in�'in w mn <br /> NNO!- <br /> TOWNSHIP PERMITS MAY BE REQUIRED O `�`�`-`��9P�P <br /> asssssssr� <br />