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�rya�yc <br /> Burnett County Office of Zoning Administrator / o Z <br /> APPLICATION_ FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and loc ited as '� h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lad Use m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wis onset. 3 0- J <br /> � <br /> o <br /> D <br /> JQ <br /> OIb WNERy(PiQase p>�tl CONTRACTOR or SURVEYOR or AGENT m <br /> t a <br /> ... .... ..f'.......w.i......•................................. .................................................................................. ......... <br /> ADDRESS ADDRESS <br /> ........................................................................................... .ADDRES....... 'S'E'S ................................................................... ......... :Z <br /> ADDRESS <br /> PHONE ... PHONE <br /> R . . ........................................................................... ......... <br /> PLUMBE <br /> WELL DRILLER <br /> O........................................................................................... <br /> ADDRESS ADDRESS G1 :r-i <br /> n o S <br /> PHONE . . . . ......................................................................... ......... � „ <br /> PHONE Z H <br /> DESCRIPTIONr <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> ......... . <br /> New Building .......... Type of Const'rurL on:_ No. Bedrooms �iz?-� n; r� 0 <br /> Atldition ,,,,,,••„ ......, ,,, /.{./,•/.y. ,,,,.••••„•••• Septic Tank Size Gals. <br /> Sanitary ,,,,}C„ Site ft. x ft. `-�.Xy�- '' _ •`S�• .J i <br /> .............. .............. <br /> Filling/Grading ,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .......................... ....... <br /> .......... .....................4.............. <br /> o <br /> Mobile Home ........ . Slope ................................ ......... M <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ......................... ......... <br /> Well home, garage, motel, etc.) Dry Well ....... <br /> Subdivision <br /> .......... Seepage Trench ......... 'a <br /> Camping Unit .......... Privy ......... :7 <br /> .................................................... Seepage Bed <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Inclu e road o <br /> Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. I1 property is located at a hi ghwa Inter- <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXI TING Aw <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 1 — <br /> ------------------------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: ' <br /> ................ ft. x .............. ft. . ............................... sq. ft. .................................................................... ........., 1 <br /> o <br /> m <br /> n <br /> N o <br /> o r <br /> O <br /> j o <br /> Fn0 <br /> 0 <br /> f r <br /> M Co -v .y m Z <br /> n Q < m c m <br /> _ F <br /> a tix) <br /> ltO. C � d cm <br /> Z oo � D a m <br /> o n <br /> W a _ <br /> �o <br /> 0 <br /> .......... . ........................... .................... ..................a................... <br /> M <br /> Signature of O net or Agent Date <br /> Remark9 //.. L`.... -L.Z'....(y.-................................................................................................................... ...... x . O <br /> \!t-`z-C•s.:� ... '.c L ..liy . ....................................................................................... ...... v <br /> �u <br /> /{ y q [. 1' H <br /> Inspection Date ..L1..-....L...- 1:....... 91�� <br /> .P:. ...1'u..f.I�,CA'G4: ;..k.�lrt_........ ...... � u N °� o � 'MM <br /> Zoning A inistrator '.� g o 0 0 0 to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures ii volving sanitary fact mics <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will lie issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval Of One Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />