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Bumett County Office of Zoning Administrator LA c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3 <br /> d ,; <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describec and '� + <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and <br /> regulations_pktt%SStaatte<of Wis o sin. <br /> ........—X././.1.: /:..`�....... .�.'.e..yl//'/(,�!!��........... .......... /VG61 r.... . ............................................... ....... <br /> OWNER (p(ll��ease print) / CONTRACTOR or SURVEYOR or AGENT s <br /> ADD...�S./... ... .k.M.pAP.'ll................................ ................................................................................... ........ a L '1 :1 <br /> ADDRESS C <br /> re �k.l....�'!�r 5......YSy9 .(.................... . ................................................................................. ........ - 3 <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> PHONE . ................................................................................. ........ <br /> PHONE M <br /> ........................................................................................... . <br /> WEL..L...D. .RILL. . .ER.............................................................. ........ <br /> PLUMBER <br /> ......................................................... .. <br /> . ............................... <br /> ADDRESS . ...... . ...................................................................... ........ O <br /> ADDRES.. S n o Z <br /> ........................................................................................... . . . . ........................................................................... ........ <br /> o .: .S <br /> PHONE PHONE 2 � r f+ <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> Nsw Building ..... .... Type o nsion: No. Bedrooms . ........ <br /> Addition ``ff OCTL Septic Tank Size Gals. . ........ I . <br /> Sanitary .......... Size . :.`.�.... ft. x ... .-�.... ft. i <br /> Filling/Grading ......... Height............. tries .. 4a. Absorption Field Site: <br /> �. �.......... <br /> Moving .......... Area Soil TYPe ........................... ........ to r i <br /> o <br /> Mobile Home .......... Slope ................................. ........ » <br /> v <br /> Privy .......... 3. Use (describe exactly, -family Perc. Rate .......................... ........ :M <br /> Well <br /> ; <br /> Well .......... hom Dry Well . ........ . <br /> garage, motel / : <br /> Subdivision .......... ary i Seepage Trench 0 <br /> /�5 M....... ... ...... Z <br /> Camping Priv . ........ <br /> v 9 Unit <br /> y <br /> p Seepage Bed <br /> ------------------------ L.`,.. -- - ----------------- <br /> Location of proposed structures and existing structures sewage systems, roads, etc., should be sketched in Fi 3. A. f .c <br /> :n <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. �`—, <br /> 1 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : O o <br /> ---------------------------------------------------------------------- <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: O ;� <br /> ................ ft. x .............. ft. ............................... sq.ft. ...... ........ ....... ....... <br /> 0. 694$ N - <br /> O N i <br /> J <br /> O <br /> 1 / To �e_ <br /> dura Zu Or, ,AIA <br /> ti v <br /> I— <br /> V O <br /> 9 <br /> a <br /> J <br /> 17 ' <br /> 75�O 5epbc- <br /> a :C <br /> 0C , W D w w m <br /> LD."a '— m m EL a y <br /> VI C' <br /> O N : `G p m m <br /> O O �uti Csde o no : D 1 <br /> 0. <br /> A . <br /> m <br /> /at <br /> Signature of Owner A ent 'o <br /> o . <br /> N <br /> Remarks <br /> m" <br /> U <br /> N ' O <br /> o : $ <br /> .......................................................................................................... ....... ............... ... . $ <br /> .. ............................... .... N N N <br /> .. w : W 7t <br /> 111'2 <br /> Inspection Date ....................................... ..... ..............`: . 1... .. . ........ o o N m <br /> m <br /> Zoning Adminis or $ $ $ $ $ y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construct; <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl cation 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 beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications 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 />