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of� comf`( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 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. N m V <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions�f. to State of Wisconsin. <br /> V. <br /> R(Please P ' t) onC- tractor or Surveyor or Agent f <br /> o = <br /> EnC�, �U1 6./ x/15 <br /> Addr s Address <br /> 1 ,� A ) Q37 FT <br /> Cit Stat Zip Cod€ City,Site,Zi Code <br /> Q cr/fin Zt, <br /> Te hone ? Telephone <br /> Colt Ja 4'e I f5 <br /> Emergency/Fire No. and Road/N"ame n <br /> )lL 0(' 0•sm I 161 .--may c-�?S n5, �ilaJed in 1L', n1� 1i <br /> Legal Description(as indicated on t statement) ;n aha-vFOF �^ g, ,SFCYir+�.10,T .-y' e✓ o <br /> Permit(s)Applied for: (" �`� a rs 80'i rrcyy o I� <br /> New Building Sanitary Filling/Grading Camping Unit m »- <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> v <br /> Structure Use: �^' o <br /> ( fami y o a in, rage,type of addition,etc.) _ <br /> � ;:JQ <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. nCA �/, o <br /> PLOT PLAN �� ( S (So C"Cif a N <br /> I Z c <br /> QWrox. ISS ° a <br /> O <br /> i &Htl)rA <br /> L� rI <br /> 1 <br /> r/1 <br /> x J <br /> o <br /> tI _ <br /> V N <br /> � I ry <br /> O v I <br /> �C —7 Z <br /> PEr(T, <br /> 736 (16 <br /> O79U <br /> PIII OZ O : <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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 G <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 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 per it county officials charged with administering county ordinances or other authorized person to have <br /> access to the at d cr' a premises at any reaso ble time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> s' ure of own uilding contract r) (date) o o <br /> ZONING ADMINISTRATOR o o <br /> TOWNSHIP PERMITS MAY BE REQUIRED c <br /> 00000 <br />