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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -00 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 _j <br /> located'as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett -.0 County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 ii <br /> tions of the State of Wisconsin. v J <br /> N d <br /> OWWN (Please Print) Contractor or Surveyor or Agent <br /> Address Address <br /> City,State,Zip a ode City, State,Zip Code <br /> I <br /> Telephon�e Telephone N <br /> Emergency/Fire No. and Road Name <br /> 14�' 2/ L6M1A La C> �A <br /> Legal Description (as indicated on tax statement ' o <br /> Permit(s)Applied for: $ <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision g <br /> v <br /> Structure Use: o o' <br /> (fa y home/cab' , ga age, 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). L 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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN _P m <br /> Z c <br /> 0 n <br /> 5 <br /> 0 <br /> J � <br /> Z <br /> I <br /> 5 <br /> w <br /> 0 <br /> 0 <br /> m � <br /> t <br /> Z <br /> 9 <br /> coo C M.0W 0aC � <br /> 0 cr 0a- m <br /> m arc - nm »nom <br /> 0 <br /> 41 `Z 4, p : ,L <br /> O � Q <br /> c N � <br /> m <br /> S 1 o c <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- o: 0 <br /> PP ( 9 Y ) Y Y a: 'p <br /> [ <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- f�+ o, m m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- r ) 1 1 <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. 1 1 <br /> „ U. <br /> SIGN HERE <br /> b. <br /> (signal e f owner or b Ing contractor) (date) <br /> ZONING ADMINISTRATOR <br /> n n <br /> TOWNSHIP PER TS MAY BE REQUIRED SS SSS lmp <br />