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Cn <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 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- 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 /> tion of the S ate of Wisconsin. v <br /> add �f�� 3 y <br /> L �l �a�[r S a <br /> O <br /> OWNER(Please Print) Cont tpr or Surveyor or Agent v <br /> f/ri"P S+. t <br /> Address / Address SO C r [-o r.k T J <br /> City,State,Zip Code City,State,Zip Code — Q <br /> S��o3 - 2, <br /> Telephone Telephone <br /> EmergencylFire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for G1 <br /> o <br /> New Building Sanitary FillinglGrading Camping Unit m .`�- <br /> Addition Privy Moving Subdivision o <br /> 0 <br /> qW.C11 we-uss. _ �rl . <br /> / Z o <br /> (family liome/cabin, garage,type of addition, etc.) <br /> 1 <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NS)and indicate North (N). <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). Q " <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. o <br /> 3 <br /> PLOT PLAN a m <br /> Z c <br /> 0 a <br /> _0 <br /> \) O <br /> J <br /> d <br /> 0 <br /> cs <br /> rn <br /> o r - <br /> J 0 <br /> v r^ <br /> �J Z <br /> r-- a <br /> b <br /> 3 N r D D W -0 <br /> mc m 0, a c <br /> C'< J man 9 <br /> 0 5 0 o 'D 3 <br /> 6'. <br /> o 0 <br /> J C' <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- - o 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. <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 /> m <br /> m <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) o: o <br /> n �' ,, ,, I <br /> Nu. <br /> o: i o <br /> ZONING ADMINISTRATORY' 'YLH7VI 6ffNo: o- , omTOWNSHIP PERMITS MAY BE REQUIRED 0 oob m <br /> 0 000rA <br />