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Burnett C-ounty 7410 Co.-Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord o 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 <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. <br /> tions of the State of Wisconsin. o v <br /> V'et-i t. C-At r <br /> OWNER(Please Print) Contractor or Surveyor or Agent ? f <br /> lUoc� Cheek <br /> Address Address <br /> S i r-e E L t S <br /> City,State Zip Code City, State,Zip Code "I 1 <br /> Telephone Telephone Cl <br /> 1 <br /> Emergency/Fire No. and Road N ^e I <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary _X_ Filling/Grading Camping Unit 0 .`.- <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: o ° <br /> (family home/cabin, garage,type of addition,etc.) <br /> Directions for plot plan drawing: IPI <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). N <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield (DF). 0 <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 /> 3 <br /> PLOT PLAN v <br /> o� � Q <br /> a <br /> o <br /> 1 J a <br /> �_ � VJ <br /> b � <br /> N � <br /> » <br /> 0 <br /> r J <br /> IN <br /> o 0 <br /> 0 <br /> 0 <br /> J <br /> 0 <br /> 0 <br /> Z <br /> N ' 1 � <br /> N � <br /> 11�n <br /> n O-G J J n CL= m <br /> N `2 N O J(D <br /> D <br /> 'Z' m <br /> Ut: F ;• : m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> C>,�: :HA; <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ;mo: G <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 :0a <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 per it county officials charged with administering county ordinances or other authorized person to have <br /> a w; <br /> access to the above d cribedpremise at a y reasonable time for the purpose of inspection. N: <br /> SIGN HERE <br /> (sign ure f owner or bui 'ng contractor) date [ <br /> CE o:n[ iro <br /> ZONING ADMINISTRATOR [nom <br /> C� jr�d m <br /> TOWNSHIP PERMITS MAY BE REQUIRED e TNN 0061 <br /> 00o 809 f/1 <br />