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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' c <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 � w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> m t <br /> Richard H. B1 kor n O <br /> OWNER (Please Print) Contractor or Surveyor or Agent m <br /> 27599 Jeffries Road e <br /> Address I Address \ <br /> Webster, WI 54893 J <br /> City,State,Zip Code City,State,Zip Code \ <br /> 866-4853 <br /> Telephone <br /> Telephone <br /> #27599 Jeffries Road <br /> Emergency/Fire No.and Road Name <br /> int 1 ('CM Vnl,mia 6. Page 52 and 5-1 .4Pr`_ 29 T40N R1 6W <br /> Legal Description (as Indicated on tax statement) 4 <br /> 0 O <br /> Permit(s)Applied for: o ° A <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit c <br /> v <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision ° $ <br /> Garage <br /> Structure Use: Sanitary Only r <br /> 0 <br /> (family home/cabin,garage,addition, etc.) <br /> 11 �Q <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). <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfield (DF). an an S, <br /> 3. Show dimensions In feet of thefollowing:(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. o i£ <br /> 4. B separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. <br /> C i <br /> PLOT PLAN M <br /> Ill <br /> W " I1 <br /> e <br /> 0 <br /> N <br /> SEE ATPACHED 0 IIIIJ`l�, <br /> m <br /> o � <br /> N <br /> n <br /> 7[� Z <br /> ( D <br /> n o c M. 0 m o a m <br /> a2. M <br /> < � ' Z 0 o 5 0 <br /> o <br /> Z <br /> P m <br /> 2 ' <br /> 8 : m a <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- O <br /> tion contained in this application(including any accompanying schedule)and I 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 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. a n <br /> i [ g�i <br /> « a <br /> SIGN HERE Wade Rufsholm <br /> (signature of owner or build'n o t to (date) <br /> o : <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP P RMITS MAY BE REQUIRED o o«8 m <br /> $ 888rmn <br />