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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m Q <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 Mc <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. m <br /> N <br /> Randy Manthie n <br /> m <br /> 614OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 842 South Pine Box 176 <br /> Address Address <br /> Grantsburg. WI 5483() <br /> City,State,Zip Code City,State,Zip Code <br /> (715) 463-5472 f <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> ncl, located in the NW 1/4 W 1/4 Sec. 34, T39N R19W. west Marshland mrx„mchin <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: G <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit c °^ — <br /> c <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision ° <br /> arm age -- <br /> Structure Use: Sanitary only c <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). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (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 Z <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m w <br /> dated by the owner. C <br /> PLOT PLAN m <br /> rn <br /> m <br /> n <br /> 0 <br /> SEE ATPACHED. <br /> c � <br /> N <br /> Z <br /> 1 <br /> g c Ma m n a F In <br /> 30. 00 a `= M <br /> 3 <br /> PZ ZQ <br /> Yom : = N : D <br /> ca : m <br /> m c C <br /> 1 declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- 5, ° 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ZS m iX E <br /> Mallon 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 W $ <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. m g <br /> 2 g2"A <br /> SIGN HERE Wade R ,fsholm wycl } <br /> (signature of owner builds g co 0 / (date) <br /> ZONING ADMINISTRATOR G [7 . <br /> TOW SHIP PERMITS MAY BE REOUIRED SEP _ 6 o o m <br />