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Burdett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Adm nistrator w o 0 <br /> • APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m v <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. w m <br /> c <br /> Arnold .Tencen n O <br /> OWNER (Please Print) Contractor or Surveyor or Agent m <br /> 27135 Jamison Road <br /> Address Address <br /> Webster, WI 54893 p <br /> City,State,Zip Code City, State,Zip Code <br /> ti <br /> Telephone Telephone <br /> 27135 Jamison Road <br /> Emergency/Fire No. and Road Name 4) <br /> txl Government Toot 1, Sec.6. T39N, R16W, Meenon Township <br /> Legal Description (as Indicated on tax statement) o <br /> o <br /> Permit(s)Applied for: 0 �. <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit S ° <br /> v <br /> Z a <br /> Accessory Building Sanitary X Privy Subdivision o <br /> n. <br /> Garage <br /> Structure Use: Sanitalzi Only �1 o <br /> (family home/cabin, garage,addition, etc.) <br /> 11 I�MII <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 c <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 v, <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building on `v <br /> measurement to the ordinary high water mark of lake,stream, or river. P Vj S <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and ' :5. <br /> dated by the owner. C O 0 <br /> PLOT PLAN m <br /> � b <br /> o <br /> ul <br /> 0 <br /> ° <br /> O Q I` <br /> 0 <br /> m <br /> SEE ATTACHED <br /> r I� <br /> z <br /> a <br /> I <br /> In c m m n g m <br /> on <br /> ro ° roZ <br /> P 1 <br /> E u y <br /> m <br /> U <br /> G) Ca 0 <br /> 8 [ a C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o ' m <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- a m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 8 m . <br /> r 3 ° <br /> ro v A a <br /> SIGN HERE 10/16/91 d, <br /> a : <br /> (signature of owner or buildi gontr o ate) c ! x <br /> /04 8i i <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP ERMITS MAY BE REQUIRED ro , o o rrn <br /> 18 $8888ro <br />