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Burnett County Office of Zoning Administr for c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •2 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the m <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. a <br /> DJ..................: !a. .N.................ly.fl.. ............ ............................ k...f...................................... ...... <br /> OWNER (please print) CONTRACTOR or SU4EYOR or AGENT <br /> .7 ....1........ .U.JI.... .6. ................................ . . . . ............................................................................ ...... a 9J <br /> ADDRESS ADDRESS m <br /> .................. <br /> ............................................ .................................................................................... ....... w <br /> ADDRESS ADDRESS <br /> G..G..i!.6.3. ....................................... . . . .............................................................................. ....... n� <br /> PHONE PHONE :W <br /> ............................................................................ .................................................................................... ....... <br /> PLUMBER WELL DRILLER ;^I <br /> . . ..... E"S" ..................................................................... ....... ; M 1.11 <br /> ADDRESS ADDRESS C :/W <br /> < �L <br /> ........................................................................................... <br /> -' <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4, Sanitary Facilities: <br /> 1. Work: - 2. New Building Details No. Bathrooms ' oUQ <br /> New Building ....✓ Typ f fo�?��r, coon: No. Bedrooms .. ....... - <br /> Addition „•,-,�� �f�l Septic Tank Size Gals. .. ....... 7 L E <br /> ... ..... ........................ <br /> Sanitary Size ...Z.G...... ft. x ....../.f... ft. •• •••"" <br /> Filling/Grading .......... Height./.A........ Stories ..../......... 4a. Absorption Field Site: <br /> Moving .......... <br /> ............ ...........Area ......................................... Soil Type ................... ....... .. <br /> Mobile Home Slope ........................ . o <br /> » <br /> Privy .......... 3. Use Idescribe exactly,'1 -family Perc. Rate ........................... ....... <br /> Well .......... home era otel,etc.) Dry Well <br /> ......... .. ....... 1 i <br /> Subdivision ,\ Seepage Trench .. ....... o <br /> .......Caf � c. ................... <br /> Camping Unit Privy .. ....... <br /> Seepage Bed .. ....... � <br /> ___________________________________________________________________ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. L c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at W g <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> 5. Lot Size: Fig. A. 6. Location: :g <br /> ................ ft. x .............. ft. — ............................... sq. ft. <br /> � AK-f' <br /> "(A <br /> T /21 <br /> LJ <br /> Z :Z <br /> a <br /> ye , <br /> m �a•< am nn y <br /> v p< d c y > > 3 <br /> p <br /> o � = m <br /> /'Fo tl J on <br /> ...... �� �....... . . y.. .. 7: o <br /> ... <br /> ...a <br /> Signature of'Dwner or Agent Date o <br /> Remarks m a ' <br /> N <br /> g <br /> ..................................................................................................... ^ ......................�1.... ............ ..... <br /> o : j <br /> Inspection Date ....................................... 1..:......G.iGl.:r: i.�. > . ... 9 vNi c°Ji� cNi� o N <br /> i <br /> Zoning Administrate 88 88 8 <br /> NOTE: A preliminary site inspection must be made and site app ,at granted on all structures involving sanitary fa Allies 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 bee i 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 AP ROVED. <br />