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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. H m <br /> m <br /> Thomas J. HaAt n f <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 4015 W. 39#h SZ. <br /> Address Address <br /> St. Louts Pcutk. MN 55416 <br /> City, State,Zip Code City,State,Zip Codesu <br /> — <br /> Telephone Telephone ``'` ` \ <br /> Emergency/Fire No. and Road Name <br /> Lot 3A CSM Vok 1 Pg 162 Sec 31-40-16 Oaktand Township <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: �. <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z <br /> v n1 <br /> ° UJ <br /> Accessory Building Sanitary X Privy Subdivision o <br /> Garage t <br /> Structure Use: Sanitah y ( nty <br /> vl o <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). O o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). o u, <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 `c <br /> measurement to the ordinary high water mark of lake,stream,or river. ro <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m m: <br /> dated by the owner. M O ; <br /> PLOT PLAN m � <br /> r� C <br /> I y <br /> CJ <br /> O <br /> 0 <br /> SEE ATTACHED o <br /> m <br /> 7J z <br /> F <br /> m o c m m o a F <br /> ro <br /> M <br /> 2 <br /> o F o E E T y ! E y <br /> u = m <br /> u 7 O <br /> C <br /> 8 ' m A <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c 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- rw m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- �m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I S 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 /> m 3 m <br /> A a <br /> SIGN HERE Wa..de RuA.6 n.Pm 12123191 N H <br /> n <br /> (signattuurre'of owner or building contractor) (date) <br /> V <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED a o o~8 m <br /> 888rn <br />