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ct <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoni g strator R 0 0 <br /> APPLICATION FOR LAND US�EPERMIT3 <br /> N <br /> C <br /> OWNER ell TELEPHONES, r$�'OS n <br /> m <br /> '! t° <br /> HOME ADDRESS <br /> EMERGENCY/FIRE NUMBER ROAD NAME g <br /> 1 <br /> LEGAL DESCRIPTION(see tax receipt) L — �— V m <br /> e <br /> DWELLING/BUILDING GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVYco <br /> TYPE OF PERMIT(S): <br /> FILLING/GRADING ❑ CAMPING UNIT ❑ SUBDIVISION ❑ /{',../}1/,�J—r/P n` <br /> STRUCTURE/ADDITION USE: �,`.�1� /0 J196/UU � ` o <br /> (Home/Cabin; Commercial Business; Bedroo eck;etc.) m <br /> BUILDING CONTRACTOR: lir <br /> v <br /> m <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 8%X 11 SHEET OF PAPER. ANY INCOMPLETE OR m 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. f e _ <br /> :C y W <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) c <br /> n o. <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m A <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE m n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO m 3 <br /> v <br /> CENTERLINE OF ROAD,(C)BUILDING(S)MEASUREMENT TO THE ORDINARY HIGH WATER MARK(OHWM)OF Z <br /> LAKE,STREAM OR RIVER AND MEASUREMENT TO WETLAND AREAS. P <br /> 4. SHOW THE LOCATION OF THE WELL(W),SEPTIC TANK(ST)AND DRAINFIELD(DF),AND ALL DISTANCES TO <br /> BUILDINGS, ROADS,LAKE, LOT LINES. a <br /> 5. INDICATE IF A WALKOUT BASEMENT IS PLANNED AND SHOW AREAS TO BE GRADED OR FILLED. N <br /> 6. IF SEPARATE PLANS ARE SUBMITTED BY AN ARCHITECT, ENGINEER,BUILDER,CONTRACTOR,ETC.,THE PLANS <br /> MUST BE SIGNED AND DATED BY THE OWNER. r'c <br /> o � ( <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q S <br /> NEEDED. (f <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. o <br /> CONDITIONS OF PERMIT: <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. VJ <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. ( I <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY r(pV/►,J <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS,ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBA7K R <br /> 5. . <br /> zv ° r- m <br /> 6. CD r-0 y 0 J 3 <br /> IP <br /> 7. G N �� M <br /> Cnm <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my L7 10 <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of o <br /> all information contained in this application(including any accompan ing schedule)and I further declare that I recognize m <br /> that this information I am providing will be relied upon by the Countynett Wisconsin in determining whether to is- w <br /> sue a permit. I further accept all liability which may be a result oft nett relying on this information I am m <br /> providing in this application. 1 agree to permit county officials d i' i g county ordinances or other m t E <br /> authorized person to have access to the above described premi t any re f purpose of inspection. -n <br /> LVVu m : <br /> m <br /> SIGN HERE <br /> (signa a of owner or building n actor8'I (date) <br /> r lJ <br /> OR <br /> Moi Alum A Beckmadr601V/'A/n_ <br /> N N fT N N V1 N <br /> //����, Ut U1 O VI(!1 O O <br /> 21387 Spook Dr. IP PERMITS MAY BE REQUIRED <br /> 0000000 <br /> Gisntaburg,W154840-8834 <br />