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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d a e <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance w@h the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a <br /> 0 <br /> regulations of the State of Wisconsin. w m <br /> Malik Chapman a <br /> OWNER(Please Prim) Contractor or Surveyor or Agent o �� <br /> 25400 Uri 35 m <br /> Address Address <br /> WebzteA WI 54893 <br /> City,State,Zip Code City, State,Zip Code ) <br /> 1715) 866-8319 805 <br /> Telephone Telephone 11 <br /> 25400 UCd 35 <br /> Emer ency.TIre No. and Road Name <br /> _pe SW 1/4 NW 1/4 Sec 29 T39N R16W� Town o{i MemoC <br /> Legal Description (as Indicated on tax statement) ° <br /> n <br /> 0 <br /> Permit(s) Applied for: $ =- <br /> '^ r <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision o <br /> Garage � <br /> Structure Use: San2tWeU Un2u - <br /> (family home/cabin, garage,addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 a <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 � z v <br /> measurement to the ordinary high water mark of lake,stream, or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. C Ilp—r- <br /> PLOT PLAN M <br /> 1 <br /> CT <br /> N <br /> V <br /> O <br /> SEE ATTACHED. <br /> o � <br /> N \1 <br /> A. <br /> Z <br /> G <br /> o c� m m o a F m <br /> m=$ a m > S. M <br /> Z f0 ? T¢ : M <br /> __ = m <br /> � g c <br /> M 8 C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl o : 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- w m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- g 8 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 Derson to have no <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 i° <br /> ro y n m <br /> Wade Rulhl^^n Pm 4/23/92 <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) ? <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIRED �N o m <br /> 888 888m <br />