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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm ; o c <br /> '-' <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the M S <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and _ <br /> regulations of the State of Wisconsin. �, m <br /> Jerry Peterson n £ <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 751 Heather Drive ° 1 <br /> m <br /> Address Address <br /> Shoreview, MN 55126 41) <br /> City, State,Zip Code City,State,Zip Code I I (� <br /> Telephone Telephone 1 - Ql <br /> #11605 Stillson Road <br /> i <br /> Emergency/Fire No. and Road Name C� <br /> Lots 3 & 4, Gov. Lot 3, Sec.34, T37N R18W, Town of Trade Lake <br /> Legal Description (as Indicated on tax statement) <br /> c� <br /> Permit(s) Applied for: 0 °. <br /> m r ri <br /> Dwelling Addition Filling/Grading Camping Unit ° I <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage 3 <br /> Structure Use: Sanitary Only t��I <br /> (family home/cabin, garage,addition,etc.) y') <br /> � J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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). 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 <br /> measurement to the ordinary high water mark of lake,stream,or river. o S <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. <br /> PLOT PLAN m �� <br /> i C <br /> a <br /> co <br /> 0 <br /> I� <br /> SEE ATTACHED m <br /> o <br /> r 1 <br /> Z <br /> l � <br /> G <br /> A o c m r n a g m <br /> m = g� aao } m ; <br /> Z 0 : i <br /> o T M <br /> m <br /> ` mei c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ' 8 i m 6 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- yy!!n p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 75 m a <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I i 900 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 ap- <br /> plication.1 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. m , F$ <br /> A w <br /> SIGN HERE <br /> Wade Rufsholm <br /> (signal of owner or building contractor) o y I <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIF�� 99 m <br /> 8$ <br /> 889M0 <br />