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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> MM <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and >2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n £ iW <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and d �p <br /> regulations of the State of isconsin. 3• a <br /> ................... ................. .. ........................................... ...... A <br /> OWNEVI Ieueprint) CONTRACTOR or SURVEYOR or AGENT <br /> � tCJO g " 1:2 <br /> 5... ........................................................................ .ADORESS.....................................................................�...... <br /> ADDRE5 <br /> ?� <br /> lj(//V�!f�fG/5......./ iY,....5�5/ 7........•............................................................................r...... O i <br /> APqRESS ADDRESS <br /> PH.17 E PHONE <br /> .......................................................... W­ <br /> .. D :W <br /> . . ..... . . .................................................................IL...... <br /> PLUMBER RILLE.. R <br /> O <br /> ........................................................................................... . ..... . ......................................................................IIS....... _ <br /> ADDRESS A..DDRES... ..S G <br /> 0 < <br /> ........................................................................................... . . ..........................................................................�....... ? <br /> PHONE PHONE...... .. Z „ r <br /> DESCRIPTION 4. Sanitary Facilities: I ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .. ....... c v <br /> New Building „ „ ,..• Ty a of Constr No. Bedrooms - <br /> Addition ,,,,�1•%QO,( ,,,•!"!S•! !('I,t,..,,,,,,, Septic Tank Size Gals. , <br /> .(/ 9 <br /> Sanitary ., .... Size ..wG.k..... ft. x .., ...yft. .. ....... .� <br /> Flllingf Grading .......... Height............. Stories .../�2... 4a. Absorption Field Site: <br /> Moving Area ............................ Soil Type ............................ ....... <br /> .......... ............ . 11 or <br /> Mobile Home .......... Slope ..................................1....... » <br /> Privy ....•••..• 3. Use (describe exactly, 1 -family Perc. Rate ...........................�....... m i <br /> Dry Well .......... ho�rtJ/e1,garage,motel, etc.) Dr Well .. ....... <br /> Subdivision .......... ..A.P..ctl.4.. ...1->-Q.!M. Seepage Trench ..L. ... o i <br /> l/ ............... / <br /> Camping Unit Privy • ••• <br /> Seepage Bed .. -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. 41 S <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located atm <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. z; <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ___________________________________________________________________ __ <br /> 5. Lot Size: Fig. A. 6. Loca�'pn: <br /> ��/1 9 '�` <br /> . .g. .... ft. x �.T.6 ft. — .....7� .6... sq.ft. .......1..4.4��.y..N0.('(... !�l Ltlt4LG4.Z�: �I <br /> r <br /> oCOUN* Y 60/ <br /> ROAD 6akA E ��1KE <br /> 0[ <br /> 0 <br /> f <br /> �4 30a q <br /> Dk'tJt 30 <br /> I Crk _ I z <br /> Fill <br /> M W N S D tD to -0 <br /> J m c =. 0 m o 0 0 <br /> n "o < 00 o = _ m <br /> 9m � 0 � g3 <br /> ° <br /> o Wo .< D ' <br /> n : y <br /> o c m <br /> o � <br /> /� .. . x ! O <br /> Signature of Owner or Agent Date g <br /> Remarks .... ................................................................................................................................... � <br /> c <br /> O S <br /> ......................................................................................................... ............... ......... Q O <br /> N <br /> Inspection Date .. ......... . ...... .. . .. .:...... .. <br /> Zonin Admini ator S S <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary falYilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applgcation 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 APPROVED. <br />