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t%( c o l-q <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ <br /> w ' <br /> ,z o <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 <br /> Oe State <br /> �of Wiscons'iin. L. Q m o <br /> OWN (Please Print) Contractor r Surveyor or Agent f <br /> P o. gd'e 3✓s Po. d6 <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code ' <br /> Telephone Telephone I <br /> ,N; h 70 <br /> Emergency/Fire No. and R _oad Na e <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit y <br /> Addition Privy ovmg Subdivision o <br /> 1 ST nWW m �yov-1 o <br /> Structure Use: <br /> (family homelcabin, garage, type of addition, etc.) <br /> 71. <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. <br /> 0 <br /> (Q 3 D <br /> PLOT PLAN <br /> A <br /> vl " � e m <br /> P <br /> 0 <br /> I <br /> 0 <br /> I <br /> co <br /> 0 <br /> o <br /> 0 <br /> N � <br /> ^ I� <br /> I Z <br /> �supc� 5—l6 SD <br /> � mv[nr D' � <br /> 0 0 .m m 0 m <br /> v< > > O <br /> a� a � <br /> c p i <br /> lD <br /> CC' O <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. rn <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 described premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> s' %Lp b�yJ�Idin ontralctor) (date) o o <br /> ZONING ADMINISTRATOR �tiL1 /t/l <br /> m <br /> NtNT f�T fNT <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000' m <br /> 0000 N <br /> iy <br />