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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITSo <br /> 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w .� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 $ � <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. H m <br /> N m <br /> Brian and Mary Peterson n £O <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 23975 Peterson Road d <br /> Address Address °- <br /> Siren, WI 54872 �J <br /> City,State Zip Code City, State,Zip Code <br /> (7151349-5373 S . <br /> Telephone Telephone <br /> #23975 Peterson Road <br /> Emergent /Fire No. and Road Name <br /> parcel Northwest Quarter, Northeast Quarter, Section 13, Township 38 North, RaigE 17 Wes <br /> Legal Description (as Indicated on tax statement) Town of Daniels, Burnett County o <br /> c� �4- <br /> Permit(s) Applied for: o �- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Zo <br /> Accessory Building Sanitary X Privy Subdivision <br /> Garage <br /> Structure Use: SANITARY only `—j � <br /> r <br /> (family home/cabin,garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X ^� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST), and drainf laid (DF). 1111 3 N <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building oz `o <br /> measurement to the ordinary high water mark of lake,stream,or river. O n I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. C <br /> PLOT PLAN m <br /> i <br /> I N <br /> A <br /> n_ <br /> 0 <br /> See attached. <br /> o I� <br /> Il }J <br /> o � <br /> V! v <br /> » I VJ <br /> Z <br /> C <br /> O C o m 2 V m <br /> m <br /> a; 2. M <br /> _ o <br /> o `>4 Cr i; m <br /> N Oc : O <br /> J g [ m C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S . m m m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- mut <br /> mation I am providing will be relied 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 ofBurnett 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 In <br /> access to the above described premises at any reasonable time for the purpose of inspection. m S <br /> m 3 <br /> m � y m <br /> 1 0//,/91 •� w g <br /> SIGN HERE Wade Rufsholm <br /> (signature of owner or b din tr (date) o x <br /> ZONING ADMINISTRATOR g <br /> rN_ <br /> TOWN IP PERMITS MAY BE REQUIREDI 0 0 9 m <br /> 8$ 8$ $ m <br />