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Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator A o 0 <br /> APPLICATION FOR SAND USE PERMITS 3. <br /> a � � <br /> OWNER 0 /o r TELEPHONE <br /> HOMEADDRESS`7 fd (�LJf//1�/ %/ O�iD �1/�O®/!/�� Cy�7v` `w <br /> CD <br /> EMERGENCY/FIRE NUMBER/ O! D ROAD NAME QI'� <br /> r? <br /> 0. <br /> LEGAL DESCRIPTION (see tax receipt) sin rn � <br /> M <br /> DWELLING/BUILDING ❑ GARAGE/ACCESSORY STRUCTURE ❑ ADDITION ❑ PRIVY ❑ c o c <br /> TYPE OF PERMIT(S): ��( <br /> FILLING/GRADING ❑ CAMPING UNIT IC4 SUBDIVISION ❑ 5 <br /> STRUCTURE/ADDITION USE: o <br /> (Home/Cabin; Commercial Business;Bedroom; Deck; etc.) a, (" <br /> BUILDING CONTRACTOR: E����� ///��'� /(����f'�y� C/5 T6-, <br /> M <br /> A PLOT PLAN MUST BE PROVIDED ON AT LEAST AN 81/1 X 11 SHEET OF PAPER. ANY INCOMPLETE OR 3 <br /> ILLEGIBLE PLOT PLANS WILL BE RETURNED. <br /> N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (AERIAL OR TOP VIEW) O m <br /> " a <br /> ,n Z <br /> 1. ALL REQUIRED DIMENSIONS OR DISTANCES TO BE SHOWN OR DRAWN TO SCALE. m W z <br /> 2. SHOW THE LOCATION AND SIZE OF ALL EXISTING BUILDINGS(EB)AND ALL NEW BUILDINGS(NB)AND INDICATE <br /> NORTH(N). <br /> n <br /> 3. SHOW DIMENSIONS IN FEET OF THE FOLLOWING: (A)BUILDING(S)TO ALL LOT LINES,(B)BUILDING(S)TO CO) 3 <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. o <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. <br /> S. 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. o <br /> O <br /> NOTE: BUILDING/STRUCTURE LOCATIONS MUST BE STAKED SO AN ONSITE VERIFICATION MAYBE DONE WHEN q 0 <br /> NEEDED. n <br /> THIS PERMIT IS SUBJECT TO ALL CONDITIONS LISTED BELOW. Z <br /> CONDITIONS OF PERMIT: o ` <br /> 1. DRIVEWAY MUST MEET DRIVEWAY WIDTH REQUIREMENTS WITHIN 60 DAYS OF PERMIT <br /> ISSUANCE. <br /> 2. REMOVAL OR CUTTING OF TREES AND VEGETATION IS RESTRICTED ALONG SHORELINE. <br /> 3. NO GRADING OR SHORELAND ALTERATIONS ARE ALLOWED UNLESS SPECIFICALLY <br /> PERMITTED. <br /> 4. NO STRUCTURES, INCLUDING RETAINING WALLS, ETC.,ALLOWED WITHIN THE REQUIRED WATER <br /> SETBACK AREA. <br /> 5. <br /> vvfD� O L <br /> 6. m3QeF?a � <br /> mcN `" o3 <br /> ' <br /> 7. z E a m °�R : ° q <br /> —� � ° : rn m <br /> I declare that this application (including any accompanying,ec edu e a ' e and to the best of my Lj p <br /> knowledge and belief it is true,correct and complete. I ack edge that I am respo b f 'e detail and accuracy of <br /> all information contained in this application(including any panyi chedule)and I furth declare that I recognize m 'm E <br /> that this information I am providing will be relied upon by unty rro I In in termining whether to is- <br /> sue a permit. I further accept all liability which may be a result,Qf the County ofBd�Yklf relyi In this information I am d <br /> providing in this application. I agree to permit county officialsd a ministering o my ordinances or other : m <br /> authorized person to have access the above described premises at s9>� r e purpose of inspection. m i <br /> 01, <br /> G <br /> i� <br /> SIGN HERE n <br /> (si_qqjjyW of own r building contractor) (date) �.} <br /> ZONING ADMINISTRATOR , 1 d, <br /> 19491.94A404A— <br /> Nfn fT NfTN0O O(1N <br /> fT � O <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 0 0 <br />