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C ( o <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Mf d „ a o�'Z <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> s <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- m `m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 n <br /> tions of the State of Wisconsin. 7� p <br /> FfrC�rAnJ_T S`lhl��? .�l /F.46014AV <br /> OWNER(Please Print) Contractor or S Ney or A ent o F <br /> Address d(, Address <br /> WeX 6� Wi <br /> City, State,Zip Code City, State,X89X (� <br /> 3�f9-593 <br /> Telephone Tel hone <br /> h4 >Z!(P fe ?ucf.rt S ti,ro — Dunn a ffP C/ K y ' <br /> Emergency/Fire No. and Road Na e <br /> �L/ F G4t� i l Rohm - (Al-9-4nef2 Z.4Ke I/Z <br /> Legal Description (as indicated on tax statement) <br /> Permits)Applied for: f/Y n <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit .`.- <br /> m <br /> Addition k Privy Moving Subdivision g <br /> Devic - / Ari Pq+0 <br /> Structure Use: <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN P N <br /> Z c <br /> tiz R Ached - Qecrc ZQ 1C Q f C/�ve thj e el <br /> o <br /> Allf'fa <br /> fr = <br /> co <br /> n <br /> 0 <br /> _ <br /> N � <br /> = } � <br /> O <br /> N � <br /> /4�� W <br /> ! ) <br /> 7" Z <br /> 1 v D <br /> m c�miu .Di rmn <br /> �1 p• m o-� »n m ,-,a y <br /> Lv_i `? N o 503 o. " � . <br /> Z <br /> �m: i <br /> m <br /> N0 <br /> O: :F,O :, 1 C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowk o <br /> MA:O; <br /> am responsible for the detail and accuracy of all informs- : ;\„o: m <br /> edge and belief it is true,correct and complete.I acknowledge that <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. 1 a E <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. i i i : is,: <br /> m N; <br /> SIGN HERE �+^�" y��7 /� �.o n?od, <br /> (5i of owner Au�ilding contractor) (date) o m :no <br /> ZONING ADMINISTRATOR <br /> • :n %�jn T <br /> NNON �+ <br /> TOWNSHIP PERMITS MAY BE REQUIRED TUNOO, xfl <br /> I o 0 0 0 0 y <br /> 00000 <br />