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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> J 3 F <br /> APPLICATION FOR — LAND USE — PERMITS d <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and `� n <br /> located at shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- O" <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of th State of Wisconsin. p <br /> t'7) �_ W, ?r5 Get. F '-N C e <br /> OWNER(Please Print) Contractor or Surveyor or Agent a O£ <br /> Address Address <br /> 3003 � —�-. �-�r-•v•v l� � C <br /> City,State,Zip Code City,State, Zip Code <br /> V9-*-//,"-4 WI 51�Sf3d � <br /> Telephone Telephone <br /> li s-- & )-& - -3 O <br /> Emer ncy/Firee Nqo. and Road Name L <br /> rs d, .. —,I-n f , {r cJ✓1 'R, �A�/JLLHY W 1 <br /> Legal Description (as indicated on tax statement) v <br /> Permit(s)Applied for: 0 <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision $ o <br /> �GvLl�n ��CP (5 <br /> Structure Use: r.�. � Zo o S <br /> (family home[ in, garage,type of addition,etc.) m u <br /> � r <br /> Directions for plot plan drawing: <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NS)and indicate North (N). , R <br /> 2.Show the location of the well (W),septic tank(ST), and drainfield (DF). Y <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 /> 3 <br /> PLOT PLAN p N <br /> Z c <br /> P n <br /> y f <br /> 0 <br /> J <br /> � e <br /> 0 <br /> 0 <br /> �3 v _Z <br /> 01 <br /> o to <br /> o <br /> I O <br /> N N W <br /> o <br /> � m <br /> N � <br /> Z <br /> I C\I <br /> p/ uev h f 7l' <br /> mc M.m 0 n a c <br /> m a< .J-�'4m as <br /> o ° =mo= 3 <br /> Z N : j N Z J m <br /> N co <br /> 2isl m <br /> of C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- <br /> 0 E y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs. C)E ; o: m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- in) O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 pillmmt county officials charged with administering county ordinances or other authorized person to have <br /> access to the above fescrlpremises at any reasonable time for the purpose of inspection. <br /> N <br /> SIGN HERE �.o. <br /> tea ; <br /> g t re of r bui[din contractor) (date) O. ; c n <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N N O O <br /> coon ggq m <br /> 0000 # <br />