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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m Co <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. N m <br /> g <br /> At Blume a f <br /> OWNER (Please Print) Contractor or Surveyor or Agent v m <br /> 27043 St. Rd. 35S. m <br /> Address Address <br /> SiAen, WI 54872 <br /> City,State,Zip Code City, State,Zip Code <br /> (715) 349-5837 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> ,Oct. <br /> Oc2 N i/2 SE 7/4 Sec 17 T38N R76E Town o4 SdAen <br /> Legal Description (as indicated on tax statement) <br /> n O <br /> 0 <br /> Permit(s)Applied for: <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> z o <br /> Accessory Building Sanitary X Privy Subdivision I <br /> Garage <br /> Structure Use: SanitaAy Uney. 5 <br /> (family home/cabin, garage,addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <br /> 3. Show dimensions Infest 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. a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m (t� Q <br /> dated by the owner. C I <br /> PLOT PLAN m <br /> J <br /> 9� <br /> I <br /> SEE ATTACHED 00 <br /> ^, o <br /> V o <br /> o I� <br /> o � <br /> z <br /> I � <br /> Arrwt q6q tv"�6IA) p <br /> / oc 0mnam <br /> FM <br /> , ma <br /> � m o. H 3: = a <br /> N m 1 <br /> o f S 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 /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. " w m N O <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor. <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ A 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> 11 <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> 000 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m . <br /> m i 3 <br /> 4/18/92 <br /> SIGN HERE Wade Rufzho& �' a <br /> (signature of owner or building con racto IP (d/a/Iok <br /> o x <br /> ZONING ADMINISTRATOR <br /> m <br /> �— <br /> TOWNSHIP PERMITS MAY BE REOUIRED �� c 9 f5 <br /> 88 8888rmn <br />