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-'v—/'71 <br /> Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < -^ :Q <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use H ?V <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0_ W :oma <br /> I <br /> N O <br /> �Drt�n /✓( . q��ono7�i 2 . NrSS <br /> OWNER <br /> L(please print+) �+ ¢ CONTRACTOR or SURVEYOR or AGENT n. N <br /> N <br /> .....................�. ............................................................................................ <br /> ........... ............... d 4 <br /> ADDRESSSS ADDRESS <br /> ADDRESS ADDRESS �\ :5 <br /> /.�9/. ..-.. ... -....:- ...Q.f................................. <br /> PHONE PHONE <br /> > .ono.Ad..panf a.1.s...................................................... ............................................................................................ y� <br /> PLUMBER WELL DRILLER <br /> c <br /> )3.ax...W.....Si> .an. Wi.......5.43.7.2.............................. . .......................................................................................... <br /> ADDRESS ADDRESS i, o <br /> ......(.7.15..463-2.333........................................................ c. <br /> PHONE PHONE z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details , No. Bathrooms .....1... o <br /> New Building „)(,,.. Type of Construction: r'p.IV1i-r!' No. Bedrooms .....2... <br /> Addition peptic Tank Size Gals. .......... u:� <br /> ......... .................. .................... 1:... Holding tank gal. 2000 ` <br /> Sanitary .....X... Size ..a. .. ft. x ....L�.. ft. .......... <br /> 1 4a. Absorption Field Site: i <br /> Filling)Grading .....,,... Height.... .... . Stories ..... .. <br /> SoilType .................................... r i <br /> Moving .......... Area ......... ....... ....... ° <br /> Slope <br /> MobileHome �. ...... .......................................... .+ <br /> Privy .......... 3. Use (describe exactly, 1 family Pill Rate ................................... It' <br /> Well .......... home,garage, motel, etc.) Dry Well """"" <br /> Seepage Trench <br /> Subdivision 1 amily home .......... <br /> . .. "... Privy i <br /> ... .............................. . <br /> v <br /> Camping Unit � - i21�-97» '�""'"' a <br /> Seepage Bed .......... .0 <br /> N <br /> Location of proposed structures and existing structures, well,sewage systems,roads, etc., should be sketched In FIg. A. Include road \ <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter V1, a W <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING Ct„i <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> 3 <br /> ----------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: O <br /> ....ate(.ii!., ... ft. x s.. ft. — ............................... sq.ft. ............................................... It <br /> J <br /> N <br /> O � <br /> _ � 3 <br /> rr <br /> 0 <br /> N <br /> Z <br /> j O <br /> N m <br /> m <br /> f 4 <br /> No <br /> �r i O 'p0 '^-O. � l a n <br /> —'� D ' a ' 3 <br /> Q <br /> Ip"fen <br /> .............................. ...................................... o c <br /> Signature of Owner Agent Date <br /> En <br /> Remarks .�ry ...L..d......C�;`-a•-E'� � p <br /> .. ............................................................................................................................................. <br /> : <br /> .............................................................................................................. .... ..... . ... .................................... .... <br /> T <br /> m <br /> ( S _ <br /> Inspection Date .. ...... ` <br /> m <br /> Zonin Administrator 8 8 8 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 be 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 the Zoning Adminlstrato,. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />