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Burnett County Office of Zoning Administrator SC <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> i <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <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 /> ........................................................................................... ........ ............... Z,f�......................... <br /> OWKR l lease printCONTR OR or SURVEYOR or AGENT <br /> 3 <br /> Gt/.. /�.f1/c ....... �/.,�`.5... � ./7�A. f` ........Ar.t!................................................................... a <br /> ADDRES ADDRESS I <br /> .........�t..�................................................................ ........... , �G'.ti�........................................................ c. <br /> ADORE ADDRESS i� ;DO <br /> /JG/��A�Q.4'. yk V3 G///S G �7 X270 s ;� <br /> PHON!/...f.:/.(......f. ...... ...................... /..................... .PHONE......... ...................................................................... t <br /> 7i.. ...........f..!.9-.36.3.................... <br /> PLUMBERWELL DRI LLER <br /> ........................................................................................... ....AD...D.......RES.............................................................................. a <br /> ADDRESS S m <br /> M 0 <br /> L <br /> .............. N » <br /> ................................................................................... . ....................................................................... <br /> PHONE PHON...... E Z � r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... fl—i New Building Type of Construction: No. Bedrooms .......... <br /> .......... <br /> Addition Septic Tank Size Gals. ..........Sanitary .......... ......................I.......................... . <br /> . .......... <br /> .. .. Size .............. ft. X .............. ft4a. Absorption Field Site: ' <br /> Filling/Grading .......... Height............. Stories ............... ;\\ <br /> Moving .......... Area ........................... ............... Soil Type .................................... i \ o <br /> Mobile Home .......... Sl .......................................... .. <br /> Privy --„ ,,,,,, 3. Use (describe exactly1 -family <br /> Perc. Rate ................................... m <br /> Well .......... home,garage, motel,etc.) Dry Well .......... z <br /> Subdivision ...... Seepage Trench .......... o <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. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at n r <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :” o <br /> ---------------------------------------------------------------------- _ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ' t N � O <br /> � W <br /> 0 <br /> Q1 <br /> \ Z ;V <br /> o <br /> d <br /> M fn -timr' D C3 to <br /> N c =. p1 G n C C <br /> n H Q < On oo o m <br /> m Nuc — a m <br /> N p O ep <br /> Z.-•O � D � 1 <br /> o �� N a <br /> o c m <br /> a <br /> o <br /> /� . .. �7 <br /> Signature of Owner or Agent Date oo <br /> Remarks 10 a <br /> 0 0 <br /> 0 <br /> 0 <br /> aru „ v Mn <br /> ....... ...... . .. .......... . . . . <br /> Inspection Date ....................................... <br /> Zoning Administr or d'IY) $ $ $ $ 41 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 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 />