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0(� cool � <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 2 o <br /> APPLICATION FOR — LAND USE — PERMITS u 3 a <br /> y <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. m <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 <br /> N d <br /> rd��s y <br /> u L n O <br /> OWNER(Please Print) Contractor or Surveyor or Agent " <br /> o � � <br /> Address Ad ress Sn <br /> c r eH t cJ L � _ ► Ll i, �,LS d <br /> City State,Zip Code City, State,Zip Code I t Q <br /> Telephone <br /> Telephone <br /> Emergency/Fire No. and Road Nj <br /> Legal Description (as indicated on tax statement) " <br /> Permit(s)Applied for: O <br /> o (� <br /> �( ` <br /> New Building Sanitary L Filling/Grading Camping Unit <br /> Xp <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> � d Sd/1; E7r�/ <br /> Structure Use: o <br /> (faamilmil <br /> y homelcabin, garage,type of addition, etc.) <br /> Nm <br /> Directions for plot plan drawing: p® <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). UJ a <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. i <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by O <br /> the owner. o <br /> 3 <br /> PLOT PLAN c N <br /> z Q Iv <br /> o n <br /> O <br /> I <br /> 2 �a <br /> OIra <br /> Iw <br /> mo <br /> — � <br /> 0 <br /> N � <br /> f Z <br /> houytJ Sc ala bK +-Ah�wa/�k <br /> V) <br /> M c w 0 a c <br /> SEP ! 5 1989 m a� a <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my kno - 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 inform A' m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this info <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit.Ph <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this apL I <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. m <br /> �y m <br /> SIGN HERE <br /> (si re of owner or ing contractor) (date) <br /> YI o1 0 <br /> o: o <br /> 7ONING ADMINISTRATOR l <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N 00 <br /> 000000 <br />