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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator iu � 0 0 <br /> APPLICATION FOR — LAND USE — PERMITSd 3. <br /> z _ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. — O �L <br /> � N 91 <br /> 7QCi�(�r <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> d <br /> Address Address J r� <br /> Ski IlLCL2ft°r /YJ,t_/ ��� )u,.l, <br /> City,/dale, ip C de City, State,Zip Code <br /> Telephone Telephone 1 ,, <br /> EmergencylFire No. and Road Name <br /> Legal Description(as indicated on tax statement) 2 ,f <br /> Permit(s)Applied for: a P. G) 1-) <br /> o iJ <br /> New Building Sanitary Filling/Grading Camping Unit y <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: o c° <br /> (family ho /cabin, gara , type of addition, etc.) <br /> Directions for plot plan drawing: N <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). f q <br /> 2.Show the location of the well (W) septic tank(ST), and drainfield(DF). V � <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. J <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- P <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 PLANZ V <br /> O Q <br /> Oa <br /> o_' <br /> CJ <br /> 1J <br /> i <br /> �I <br /> C1- ~ <br /> � <br /> aa <br /> o <br /> O <br /> N � <br /> Y Z <br /> I/ <br /> C <br /> ry c�N N o a C m <br /> m nom '- nm aa � <br /> D < d C y 3's, <br /> N N O M m <br /> Z <br /> o Ch <br /> _ A m <br /> rn: cc O <br /> o p; C <br /> _. <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- o E p, <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- rr0o In <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infer. <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 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 /> T i�q <br /> SIGN HERE 1^ <br /> (sign re caner o g contractor) date) <br /> o; <br /> ZONING ADMINISTRATOR n <br /> NT <br /> TOWNSHIP PERMITS MAY BE REQUIRED 1�y� n rllp_� <br /> oou, m00000N <br />