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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 j l"1 � <br /> Office of Zoning Administrator w m a a <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. U� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a mr\ <br /> tions of the State of Wisconsin. <br /> james 4 jol-f `T�yfelf <br /> OWNER(Please Print) / Contractor or Surveyor or Agent a F <br /> t/6 Dekk"a re ,4ve . w <br /> Address Address <br /> VV, fr- AG) � AM. s-silir / <br /> City,State,Zip Code City, State, Zip Code V� gT <br /> &12 - 4S7- iPp7 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> z�83 <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition �_ Privy Moving Subdivision g <br /> Structure Use: c14h — SG I'PPh ,Eb yc`, a <br /> Z o Q <br /> (family home/c in, garage, type of addition, etc.) o <br /> Directiole 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 lt,ation of the well (W), septic tank(ST),and drainfield OF). o <br /> 3.Show the locnion of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 300 ft. <br /> 4.Show dimensiot. 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 m:.k of lake, river or stream, if applicable. <br /> 5. If, separate plans are-,bmitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. O <br /> PLOT PLAN a U1 <br /> Z c� <br /> P n <br /> 0 <br /> N <br /> = l O <br /> -YJ = a <br /> 0 <br /> 5�' I SJ <br /> d- s <br /> w <br /> ua-uaa )`i' <br /> F1l_l <br /> �3V N <br /> O <br /> 3� X3(7 '- <br /> o � <br /> ,3p0 i <br /> Z <br /> /oo ( !oo /00 e /Q. , Soft <br /> p (n V U)r­DD co y <br /> l m cM.00 oac <br /> Co or oa_ M <br /> FVi5h%j CQA61^ &w5/ IW ' 1� 1 ' t�h� )6' .10 �� 9 000O= 3 <br /> � m <br /> CnO <br /> of i c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- �o 0 � <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- ,{ ' A m <br /> I ion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- J:.tr <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I a E <br /> ng in this ap- <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providiplication. 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 /> m <br /> SIGN HERE <br /> (siure of owner uilding contractor) (date) o' o <br /> ZONING ADMINISTRATOR --�Jh7 !�+-� O' o i E [ o <br /> TOWNSHIP PERMITS MAY BE REQUIRED NNONJ N m <br /> cn ut v.ut o v' <br /> �00000�oN <br />