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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Admin)#trator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 9 <br /> m o <br /> TO•THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q w Ri <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the $ V-- <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. a m <br /> w w^ <br /> c O <br /> OWNER Ec 111 TELEPHONE (612)448-3082 o m <br /> JO(X� rair)�e�/ Pl• m <br /> ADDRESS 16315 C. Rd. 45 Carver, MN 55315 -' <br /> EMERGENCY/FIRE NUMBER ROAD NAME Mitchell Road <br /> LEGAL DESCRIPTION (see tax receipt) Lot 14, CSM Vol. 11, Pg. 192, Section 14, T40N, Rl 5W, O <br /> Town of jackson <br /> CONTRACTOR , <br /> TYPE OF PERMIT(S): DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ADDITION o <br /> 0 V <br /> SANITARY % PRIVYo <br /> FILLING/GRADING CAMPIN NIT SUBDIVISION o <br /> w » <br /> STRUCTURE/ADDITION USE: SanitaIy '� e o <br /> (Home/Cabin;Commerc sl Business;Bedr m;Deck;etc.) Z o <br /> o c <br /> m <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) {,7/ <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate Non I (N). I(Jr <br /> 2. Show the location of the well (VV),septic tank (ST),and drainfleld (DF). g <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building y„/ <br /> measurement to the ordinary high water mark of lake,stream,or river. C <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 9 <br /> dated by the owner. C <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED FOR ONSITE VERIFICATION BEFORE A PERMIT CAN BE 13SUED. 11 a <br /> PLOT PLAN o <br /> M D <br /> C ' <br /> A ct <br /> c <br /> s <br /> SEE ATTACHED to <br /> 0 <br /> o' <br /> 4 � <br /> w ItGvL <br /> .. I <br /> Z <br /> G� D <br /> rn <br /> I <br /> 1 <br /> i; <br /> CONDITIONS OF PERMIT: Q C 8g,3 ; <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT ISSUANCE. c ` IQ ' � <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY PERMITTED. ' r" O i IT <br /> P ` C <br /> I declare that this application(including any accompanying Schedule)has been examined by me and to the best o my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of JI informa- �+m �+ m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize th this infor- $ E O <br /> mation 1 am providing will be railed 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 providinj In this asp- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized per n to have ` <br /> access to the above described premises at any reasonable time for the purpose of inspection. r <br /> w <br /> Wade Rufsholm 10/25/94 <br /> SIGN HERE <br /> (signature of ow 11 ng c t to (date) + <br /> S <br /> ZONING ADMINISTRATOR '. 8 : ' ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED X RIO m <br /> c $ 8$888 fn <br />