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yr ) Coir <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <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 � m 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 /> tions of the State of Wisconsin. o <br /> IUQJ )l�mC� l7 i �Clr \ II c <br /> OWNER(PI aseLP1ri�nt) C 3r -37 <br /> _ Contractor or Surveyor or Agent o G F <br /> l�( J <br /> Address Address <br /> fgels ss `J1l9 <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> -z Qzb � w . L Pse } i 6Q d rci <br /> Emergency/Fire No. and Road Name <br /> � t1 T39 C) te ( Li W Pu Gov, Lo-t- SE <br /> Legal Description(as indicated on tax statement) v <br /> m <br /> Permit(s)Applied for: 0 G1 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> m <br /> Addition /_ Privy Moving Subdivision g o <br /> Structure Use: U ��a q z <br /> 0 <br /> (family home/cabin, garage, type of addition,etc.) P m <br /> a <br /> c <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). I <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 /> PLOT PLAN a <br /> sem 4 tictcyl Q U <br /> n <br /> m <br /> r/ 0 <br /> W = <br /> a <br /> S <br /> � s <br /> y <br /> Q n <br /> 0 O <br /> s <br /> m <br /> 0 <br /> N <br /> p Q � oe� <br /> MAY � ' No M m pt r- D D co <br /> �R/ m `a<> > o aE- m <br /> m a`c =am c;a � <br /> c < m C m O 3 <br /> y ? O p <br /> i i it 0 <br /> oQ <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i :m — <br /> edge and belief It is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- rr 11''" i Em oA <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 '• m 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 b'• '• ;.� <br /> access to the ove described premises ata reasonable time for the purpose of inspection. = «» <br /> N: <br /> CD: <br /> ( ' nat a of owner ilding contractor) (date) <br /> TOR gm ' ixS <br /> • rf r. n M -r <br /> Q� �OcroP <br /> TOWNSHIP PERMITS MAY BE REQUIRED M <br /> 1io00a0o Rm <br /> oQQOOO rA <br />