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4) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v 'a 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 v H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m ; _ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. w m f <br /> Duane Jackson a ., o <br /> OWNER(Please Print) Contractor or Surveyor or Agent m <br /> 11565 North Fork Dike Road <br /> Address Address <br /> Grantsburg, WI 54840 v <br /> City, State Zip Code City, State,Zip Code ' r <br /> 015) 689-2213 ( ✓� <br /> Telephone Telephone � 1� <br /> 11565 North Fork Dike Road <br /> Emergency/Fire No. and Road Name L <br /> NW 1/4 NE 1/4 Sec. 34, T39N, R18W, Town of West Marshland <br /> Legal Description (as indicated on tax statement) \ <br /> n L) <br /> Permit(s) Applied for: o 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> z o <br /> Accessory Building Sanitary X Privy Subdivision P <br /> Garage �. <br /> Structure Use: Sanitary Only N <br /> (family home/cabin, garage,addition, etc.) <br /> O � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) A <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building q z <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C I <br /> PLOT PLAN m Uj <br /> Q <br /> N <br /> n <br /> o' <br /> N <br /> 0 <br /> SEE ATPACHED o <br /> o y <br /> IJ ,1 <br /> z <br /> N <br /> f <br /> A o c m r n F m <br /> � n � <br /> 00 M0 3 <br /> 2 m o m Z : 1 <br /> fes : r M <br /> _ � m <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> 5- ig ` i m a ? i M <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- u m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this a2-_ <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 8 n <br /> D O A u <br /> m m <br /> SIGN HERE Wade Rufshol-m 10/26Z9] <br /> (signature of owner or buildinnggccontracto / (daatte) c <br /> ZONING ADMINISTRATOR 7/ <br /> TOWNSHIP PERMITS MAY BE REQUIRED ( o o m <br /> $ 888rmn <br />