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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w m o a <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> N O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m 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 Wifsconsin. <br /> DOF GEoRGIA BEW-8 <br /> N � <br /> OWNER(Please Pr' t) Contractor or Surveyor or Agent a <br /> 8/ �� la k �e r -rra� <br /> Address <br /> g-�ddress <br /> iJZbLkk tJT, t?So t �� <br /> City,State,Zip Ccfde City,State,Zip Code <br /> Telephone Telephone <br /> PC01(o Black Ae-ax Tra1 <br /> Emergeyl dire No.Jng Flo d Nams a ie'e <br /> Legal Description(as indicated on tax statement) p (ttt�111uttt+ <br /> Permit(s)Applied for: `^ o <br /> New Building Sanitary Filling/Grading Camping Unit w <br /> Addition Privy Moving Subdivision g <br /> /'� v <br /> Structure Use: Gr ra' P w <br /> (family homelcabin,garage,addition,etc.) <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). <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 lake, 0 <br /> river or stream, if applicable. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 <br /> the owner. on 93 m <br /> c <br /> PLOT PLAN o n <br /> too Fr. W M C) Q1 <br /> 68 ® IJ <br /> C9 <br /> T <br /> i. NB Q D� <br /> e m o <br /> o <br /> N <br /> �3f r <br /> C 6Q <br /> z <br /> )) > �s` r� owjr- <br /> E6 - a(o 38 NawsE a) lifi (24b) 3o�t � r <br /> Al l3 - _2y X <br /> m g� 5nm arLM <br /> 0 0 0 IC <br /> W N O OO <br /> 2 G <br /> V E tjn ` rn <br /> : rn <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: m � : ? A <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- - m <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. 1 <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 /> SIGN ,�HERE <br /> (si ur of owner or ui ing contractor) (1 4t �1 �_ -� E <br /> -- -- ;P <br /> ZONING ADMINISTRATOR <br /> � ! NN�WlAHN 7I <br /> TOWNSHIP PERMITS MAY BE REQUIRED SEPi I N N g g m <br />