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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THF, ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <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. / o Vf e h y n. <br /> ur 1, C TX a 4 C h <br /> �° o <br /> OWNER(Please/�Print Contractor or Surveyor or Agent <br /> 7 m to A <br /> m <br /> Address Address <br /> .Dcn k 1.4 wi <br /> City, State,Zip ode City,State,Zip Code v 1 <br /> Ic <br /> Telephone Telephone <br /> I � � <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) C o <br /> p <br /> Permit(s)Applied for: n O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 5 » p <br /> m r <br /> Addition Privy Moving Subdivision g o �- <br /> v r. <br /> Structure Use: Z o <br /> (family homelcabio, garage, type of addition, etc.) <br /> (� i— <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). C> (v <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield (DF). l N <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. N <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 ppC� <br /> PLOT PLAN UD <br /> 0 Q <br /> 0 0 <br /> o' <br /> J <br /> 7 C_ <br /> 4 <br /> o >' <br /> f <br /> o <br /> J <br /> 0 <br /> O <br /> N V' <br /> Z <br /> �0 <br /> 1 11V <br /> cpo c°w0 naC m <br /> n 0'< JJ 0o.-. m <br /> o °Cyo= 3 <br /> C m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl o: 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- o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. o: O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I -P <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 v <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (signal e f owner <br /> ilding contractor) (dale) E o! [ o <br /> ZONING ADMINISTRATOR <br /> J o <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED d oLl o 6 6 o m <br /> 000 000f/1 <br />