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19 <br /> Burnett County-7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> O �\ <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w ` \ <br /> located as stiown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m C, <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n _Q <br /> regulations of the State of Wisconsin. m <br /> Wilkie Petersen g r o <br /> f <br /> OWNER(Please Print) Contractor or Surveyor or Agent !tm' <br /> 26198 Old 35 Rd. <br /> Address Address <br /> Webster, WI 54893 <br /> City,State,Zip Code City,State,Zip Code - <br /> 866-7216 <br /> Telephone Telephone <br /> 4 <br /> Emergency/Fire No.and Road Name I v <br /> SW 1/4 NE /4. Sec. 24, T39N, R17W. Tbwn of Lincoln L� <br /> Legal Description (as Indicated on tax statement) <br /> ct <br /> Permit(s)Applied for: o It. <br /> ^ r n <br /> Dwelling Addition Filling/Grading Camping Unit S o <br /> v <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision ° m <br /> Garage <br /> Structure Use: Sanitary Only U <br /> (family home/cabin, garage,addition, etc.) ` <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 3 <br /> 3. Show dimensions in feet ofthe following:(a)building to all[at lines,(b)building to center line of road, (c)building Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m -- _' <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> 4.> <br /> i <br /> i <br /> 3 <br /> o <br /> SEE ATTACHED ry <br /> o <br /> o � <br /> N <br /> IZ <br /> m o c =. m m o a g m <br /> n <br /> Z o m Z =1 <br /> 0 <br /> M <br /> C <br /> mom : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- a m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro �, <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 go 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 /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described promises at any reasonable time for the purpose of inspection. m _ ; 3 <br /> re8Y : <br /> € 8A1: <br /> SIGN HERE <br /> Wade Rufsholm 9/23/91 <br /> (signature of owner or building contractor) - E <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIREO SEP 2 3 1991 Na o o~S m <br /> 8 N888v, <br />