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Burnett County Office of Zoning Administrator e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> m <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 nd 3 `8 <br /> regulations of the Slateof Wisconsin. S <br /> C...�i.t./...... lett /2.1�................. ........ i c?/. 1 ......... 41.N..�r!� .;.......... ...... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT 1 <br /> ,Or ! $iZ7z....Gtll............... .............�� .../.......�{ ....../�2..W!......... ...... s <br /> .......... .......... .............. ........... . <br /> ADDRESS ADDRESS I <br /> : t <br /> ADDRESS ADDRESS <br /> ............. .................... .......................................................... ... <br /> PHON .1 <br /> r PHONE <br /> 71 <br /> .. ................................................................................. ...... <br /> PLUMBER <br /> -c�4 WELL DRILLER <br /> ... .. . � <br /> ADDRESS <br /> 7�1...... � .yy_ 35 .' l` � <br /> . ... . . . ........................ .... ..................... . ................................................................................... ...... » n \ <br /> PHONE PHONE <br /> DESCRIPTION <br /> P <br /> Z <br /> 4. Sanitary Facilities: o : ti <br /> 1. Work: No. Bathrooms ? I <br /> 2. New Building Details C:) o 'v <br /> New Building ..... Type of Constructio,�.: No. Bedrooms ...... <br /> Addition ...,,,,,,, • wF.. ...../.:lf'An�E Septic Tank Size Gals. ',7 <br /> Sanitary ... . .. Size ....cuff.... ft. x ....A.0... ft. <br /> Filling/Grading .......... Height.......rS'.... Stories ......{........ 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ................`. ....`.:.... ...... .r <br /> Mobile Home Slope ....................... � . .. ...... <br /> Privy .......... 3. Use (describe exactly, -family Pe�. Rate ...................... .:... ...... o l <br /> Well .......... ome garage motel, a c. Dr Well ... ...... <br /> f—� I . --- Seepage Trench Z <br /> Subdivision .......... .....(...rrS14(!.try...tfCl.E......... ... ...... o <br /> --Camping Unit— Privy ... ...... <br /> .......... .................................................... <br /> ------------------------------------- Seepage Bed ----/g)`. ._— � <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at (� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :I til o <br /> ----------------- <br /> 5. Lot Size t ---------- ----Fi A. 6. Location. <br /> ` n g. <br /> ..K.�.Q...... ft. x ...�....�.. t�/.��!.'.............. sq ft <br /> lire! G �t <br /> (mil Lc $ifLrla`� Sc ✓�o'r�� o' ' t 0 <br /> A7�� o <br /> d <br /> M Q) -o r- D do W <br /> 0 »Q < 000 In <br /> m Nn�c -� nm ash <br /> o .'n i5 : �2 a -4 <br /> Nom . ya ' <br /> l — o : m <br /> D n O <br /> Z.... ...r. <br /> 4/te <br /> �L..!�� n : mSignature of Owner or Agent o <br /> o , <br /> Remarks <br /> m •• <br /> o , g <br /> 0 <br /> ........................................................................................................ ..... ................ .. .............................................. ... o <br /> Inspection Date ....................................... .. ..• ... N o o N m <br /> Zoning Administrator 8 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and s e approval granted on all structures involving sanitary fac lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />