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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator („� M 0 0 <br /> '— 3 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> - 0 1 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit f r the work described and 0 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordancg with t� requirements of the Bur- 0 <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, <br /> p d <br /> //^+�i/n f��f/f� G//2�SG�I SG <br /> n £ <br /> OWNCR(Please Print) eContractor or Surveyor or Agent o J <br /> m � <br /> Aj7 <br /> Address 1 Address <br /> r r i ✓aY l 17/ �.�:s c SSC�7 i! <br /> City,State,Z p Code U%rRK IK'nF City,State,Zip Code <br /> 61/ 2- Lr3 - SSS #e'a <br /> Telephone --�� Telephone <br /> olf'//�/S'C�itl &4/l <br /> ci <br /> EmergencylFire No. and Road Name <br /> Legal Description(as indicated on tax statemen <br /> Permit(s)Applied for: o M <br /> 0 <br /> New Building Sanitary FillinglGrading Camping Unit y <br /> ip <br /> Addition Privy Moving Subdivision o <br /> o <br /> Z <br /> Structure Use: E���� , m� �y 0 <br /> (family home/cab' , garage, type of addition,etc.) 7L <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 feel 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 /> n <br /> the owner. o <br /> 3 <br /> PLOT PLAN N <br /> Z Q <br /> a <br /> I o <br /> I co <br /> i76 <br /> Rw <br /> J <br /> Jn �. <br /> cm.ww <br /> 1 <br /> .Y j 7�� JJ mvmr oacDDao � <br /> No a� =am as 31 <br /> �• v �� n .Jl <.. mc2o� 3_ <br /> Z O. N � : 1 <br /> O: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m o RI <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. 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 o v <br /> access to the above described premises at any reasonable time for the purpose of inspection. "^ <br /> O <br /> ;7 Ar :a <br /> SIGN HERE m'4 <br /> Jh{� : V <br /> (si at a of own o ding contractor) (date) o o$ <br /> 1117 <br /> p ob : :Op <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED �� Boo m <br /> S� oto o�' !p <br />