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C) � ('(" i I ) T-A <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator do 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 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 0- <br /> tions of the State of Wisconsin. H o <br /> 0 <br /> OWNER(Please Print) Contractor or Surveyor or Agent E <br /> o � <br /> 1 R M.R1iw f /J J L.ts dAA� -7/- <br /> Address <br /> 7/Address Address <br /> V'��t9SA4- le,i s2 ad 640 s&At /AP o _rVe jbr <br /> City, State,Zip Code City,State,Zip Code <br /> e�,gda " U 5 2. s® 79 3 a -W jg <br /> Telephone Telephone <br /> Z724-> ,4 n .7 <br /> EmergencylFire No.and Road Name ►, <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: 0 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit u0'. <br /> Addition Privy Moving Subdivision o <br /> �Off �iE - l .y ��rnr- S� S�oc.oC.� a <br /> Structure Use: x o 9 <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. ct <br /> 3 (} <br /> PLOT PLAN -O rd <br /> Z <br /> 0 Q <br /> n <br /> 5 <br /> rn <br /> See 47 40_dPlot <br /> 3 <br /> . <br /> I � <br /> 0 <br /> �J <br /> o <br /> O <br /> N � <br /> Z <br /> l <br /> C <br /> M roTmrD <br /> n Q<» m <br /> D <br /> m C M <br /> D <br /> Z o : Z —I <br /> O U : <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- J-= A m <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 [ <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 descr' d pre 'ses at any reasonable time for the purpose of inspection. <br /> � m <br /> SIGN HERE / �61� in <br /> (,>kJ9ure of_owDertrsuildlng contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> T <br /> s V N O N <br /> T TN T , O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000�rmi) <br />