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Gi� r o(r) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d �7 a o <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ <br /> d = <br /> L <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and a m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- L� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tion f t e State of Wfpconsin. UT <br /> t ner�'nn! S e <br /> a O <br /> OW ER(Please Print Contractor or Surveyor or Agent o <br /> Ad,,ess Address <br /> o I m(Jf I-�is �►� spa <br /> City,State,Zip Code City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. anc Xog tRameQ <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: 0 o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> AdditionPrivy Moving Subdivision 0 a <br /> Structure Use: _` —/3- r-r4co <br /> 0 <br /> Z <br /> 0 <br /> (family home/cabin, garage, type of addition, etc.) <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). <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 /> 0 <br /> 3 <br /> PLOT PLAN 9 <br /> Z = <br /> o Q <br /> a <br /> (' � 0 <br /> &J o <br /> J <br /> i <br /> I ao <br /> N <br /> 13 to <br /> s e,, <br /> C;dd0aa' v <br /> m n� -'nm »ay <br /> y `z N O J 10 <br /> N <br /> Tn m <br /> o€ C ` <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o E <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- c An <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 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. 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 /> T <br /> SIGN HERE <br /> (sat a of owner or it 'ng contractor) (date) o o <br /> f <br /> ZONING ADMINISTRATOR <br /> / TOWNSHIP PERMITS MAY BE REQUIRED 5Lo N o v j jpT <br /> N U O N O pO <br /> O O O O S O O <br />