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tf 1 co frt� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 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 <br /> s <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- cl� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a i <br /> tions of the State of Wisconsin. <br /> IZUt p 1��1uuklrJS �F���—�e� ��rucFt��n = Ul <br /> O NER(Please Print) ContractoY or Surve or or Agent °' F <br /> 55 L p 5T 3 � 0 �'� . <br /> Ad ress Address I <br /> l�� tn�nou7'� 54oi5 )� �Ak E_ ( ,S--4Q3o <br /> City,State,Zip Coo a de T— City,State,Zip Code I <br /> 79(j2- 5aio 7r Sal- 3�ss <br /> Telephone Telephone d <br /> Z(eb'1a1�r /l t('n d <br /> Emergency/Fire No. and Road Name <br /> SC a5- 39 347/9al 449l.ab SA5I14019/4 uj PCL 40 14 0?15- <br /> v^ <br /> Legal Description (as indicated on tax statement) pCL G"OV LoTq Lots /74lov 06300 � <br /> Permit(s)Applied for: O <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition �_ Privy Moving Subdivision $ <br /> Structure Use: {ndU Q1191AJa o <br /> (family home/cabin, garage, type of addition,etc.) 'm <br /> a <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 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. n _ <br /> 3 <br /> PLOT PLAN _ y <br /> Z c <br /> ° n <br /> NN <br /> 0. O <br /> J <br /> rj <br /> � s <br /> A <br /> f <br /> a <br /> LA Z <br /> N <br /> n <br /> N <br /> IfV1 <br /> i0 <br /> z <br /> pr� 6r� od � ��C <br /> NSR V R � <br /> m c �.mm nac <br /> ° o-'< JJ na <br /> -. m <br /> m a`c am ^;aic <br /> rnE � 0 O Jm <br /> n N` m <br /> Ute p <br /> o: it oi; C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o �� a j 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 -= : Ao: m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 01 0 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I : imp <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 /> ,p tN <br /> 'SIGN HERE gd <br /> N^' a: <br /> om :: n: <br /> o(satur, of owner ding contractor) (date) on <br /> ZONING ADMINISTRATOR <br /> n a, <br /> ea T <br /> N N O N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED n nu noo <br /> oogoobgm <br /> 00 000 N <br />