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b ('Lwi <br /> Burnett County Office of Zoning Administr for gn ;? o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements ol the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> ..............a*/z..(5...pe0.v ffu"................................. ..................................................................................... ...... n � <br /> OWNER(please print) CONTRACTOR or SURVEYOR or AGENT <br /> ri <br /> ADDRESS ADDRESS <br /> I...(�1�...�j....,51 3........................................ .. ............................................................... .... <br /> ADD ESS ADDRESS <br /> 7/5 3i 7343................................................ ..... .............................................................................. ....... ) <br /> PHONE.. ................... .. .. PHONE ...... <br /> .u/ade ,Qu�slu/m.............................................. .................................................................................... . <br /> PLUMBER WELL DRILLER <br /> .................................................................................... ....... o <br /> ADORES� ADDRESS <br /> 0 o :Cc) <br /> (9/sPLoG - 2710 ........................................... ....... o <br /> PHONE................................................................................ PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: , ° o ° :<]" <br /> 1. Work: 2. New Building Details No. Bathrooms .. .. .... o (lam <br /> Nev, Building Type of Construction: No. Bedrooms .`5.•... p <br /> Addition .................................................... Septic Tank Size Gals. ...Q. . <br /> Sanitary . ........ _ <br /> . ........ Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area .. Soil Type ........................... ........ <br /> Mobilia Home o <br /> Slope .................. <br /> .......... <br /> ... ..... ........ <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .......... :................... ........ i <br /> Dry Well <br /> Well ,......... honearage, motel,etc.) """" Z <br /> / Seepage Trench o <br /> Subdivision """" <br /> (y..lro. �............ <br /> Camping Unit Privy <br /> .......... .................................................... .✓.. <br /> Seepage Bed --G. : - <br /> . ........ 1 <br /> Location of proposed structures and existing structures, well sewage systems, roads, etc., should be sketched in Fig. A. C <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. = <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. .w <br /> ------------------------------------------------------------------- -- it <br /> 5. Lot Size: Fig. A. 6. Location: `�— <br /> ................ ft. x .............. ft. — ............................... sq. ft. ..................................................................... ......... � <br /> N o <br /> o <br /> C � O <br /> JZ <br /> O <br /> m <br /> ua <br /> D N Vin r- Dto W -0 <br /> m <br /> o oom _ o �m ; <br /> Z--•o D <br /> o m <br /> » 0 : O <br /> o A y <br /> n : m <br /> ........................................................................... ...................................... <br /> Signature of <br /> O ner or Agent Date $ <br /> Remarks .. - �'C.'i1- ;;r" <br /> N <br /> a : g <br /> .......................... ...... <br /> Inspection Date . .` .,�.:-... ............ ...... . . .. .......... ...................... . v, N V7 O O N m <br /> Pe Zoning Adm trator o 8 g 8 S o f/1 <br /> NOTE: A preliminary site inspection must be made and si proval granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this spit lication 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 ben issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans o specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />