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Burnett County Office of Zoning Administrator - o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 0. <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. rA o <br /> w m <br /> c <br /> OWNER(Please Print) Contractor or Surveyor or Agent ii E <br /> DALE PETERSON MEL J. FERGUSON d m <br /> Address Address m <br /> HCR59 1105 WEST POINT RD <br /> City State Zip RoWI 5801 city,State,Zip code <br /> Telephone Telephone Ji <br /> Permit(s)Applied for: � O <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> SanitaryX Camping Unit <br /> Privy Subdivision o <br /> Structure Use: a <br /> (family home/cabin, arage,additi n,etc.) Z <br /> o ° <br /> a <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). .� o <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 lakeo, 0 , <br /> river or stream, if applicable. U,J <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. <br /> M <br /> a <br /> 3 M <br /> AS ATTACHED <br /> C o $ <br /> C ul <br /> � 11T1 a <br /> n <br /> e <br /> w <br /> II o <br /> NJO <br /> O <br /> in <br /> � w <br /> m O <br /> O <br /> N3 I� <br /> m <br /> _ Z <br /> 0 <br /> Z <br /> � a <br /> f <br /> M Nvmr>>to-0 <br /> rwi v<> > 0ncm <br /> 0 0.-- <br /> m nuc a0 ny <br /> Z 0 : <br /> O > ; <br /> m: A <br /> N` i o E€ O <br /> i C <br /> 1(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to c <br /> the best of g; ? E <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are) responsible for the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- b; <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the , O; <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described r <br /> mises at any reasonable time for the purpose of inspection. <br /> °, m-ts Dnp <br /> SIGN HERE <br /> (signature of owner or build' contract ) ( ate I o <br /> v )JUI <br /> ZONING ADMINISTRATOR I m <br /> - N. v • oo� m <br /> TOWNSHIP PERM TS MAY BE REQUIRED 8- aa68cmn <br />