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0>1 ('cfl� C_ <br /> Burnett County :410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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- <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. <br /> rn O <br /> N <br /> JtQoiwr D. JW_IA�A M _ TucL �f}<LPf Q tjicOC O` <br /> OWNER(Please Print) Contractor or Surveyor or Agent a f <br /> o � <br /> Address Address - <br /> /7q✓✓ �✓R� uii5 c Sti' 83D DAr L7u(Z y 1,/15 c s `ld'�O C <br /> City,State,Zip Cotla City,State,Zip Code ) fi <br /> S 1.j / r4s T7I IJ r c„�• c r. <br /> Telephone Telephone <br /> Jr; 4,s( - - 7 I -� 1J- � S(o - 35.5 <br /> Emergencyl"/F,',ire No. and Road Name r1 <br /> Legal Description (as indicated on tax statement IS ya Fy J jZ 1 4 j3-11 Z3 N Zo /° 0 0 <br /> Permit(s)Applied for. S /•�'r'N/// ,yy,�, « A N�/F1: S . 77 0 o (V <br /> New Building Sanitary PG Pil1inj/Ld'kg- y Z-s �A—` ° mping Unit m ^`c <br /> Addition — Privy Moving Subdivision jj o <br /> Structure Use: � «X J � dJa�I ��K' , 1 � 0v <br /> _ <br /> o <br /> (family ho elcabin, garag type of addition,et-c)\ <br /> r <br /> Directions for plot plan drawing: C <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). 0 <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 Tires,(b)building to center line of road,(c)building to ordi- <br /> nary high water mark of lake, river or stream, if applicable. 4.7^�/ <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 /> O <br /> 3 <br /> PLOT PLAN p w <br /> / Z c <br /> o a <br /> ! y <br /> r O <br /> 7 <br /> a <br /> (�eL-TC <br /> r <br /> � 1 <br /> fp <br /> 7S7 T 7 <br /> Sr to <br /> �0C1 <br /> f: rT_ <br /> • 0, Zu N <br /> 0 <br /> --o <br /> �— I c <br /> 35,0�l �r _ - N <br /> ,' r 4 z <br /> � I Zg5rT <br /> 33 mv(nr W 9 <br /> Q<> > n o.c m <br /> DO - aS <br /> - - a < : me o � 3 <br /> m : 2 o <br /> z o: z ' <br /> _ «€ € m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- r o I 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- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- O 0 <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 aboved ribed premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (s' na re of owner ilding contractor) (date) o o <br /> ZONING ADM4I <br /> w M <br /> N O N �N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED c o o Po 00 D o m <br /> 00oo 000f/1 <br />