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Burnett County Office of Zoning Administrator d - 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and loc ited as 57 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County La id Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wis onsin. 3 a <br /> e a <br /> 1W111-2X4A%.........�G "ne) ................................. .................................................................................. . ia d �o <br /> OWNER (Please print) CONTRACTOR or SURVEYOR or AGENT a » <br /> 5...7` r...... ia <br /> ...../�.t........ ��x s <br /> ..................... .................................................................................. . <br /> ADDRESS ADDRESS <br /> Zell <br /> ...... ................................................................ ................. ......... ^ <br /> ADDS ADDRESS <br /> I <br /> __ .� . <br /> PHONE PHONE ' <br /> m..�z :. . ......... <br /> PLUMB RWELL DRILLER : !r <br /> ADDRESS................................................................. <br /> ADDRESS .. Oo <br /> 7/..5�........' 9...' ..3I................................ ................................................................................. .......... !� <br /> PHONE PHONE ' <br /> DESCRIPTION 4. Sanitary Facilities: ° o o '� <br /> 1. Work: 2. New Building Details No. Bathrooms .. o <br /> New Building .......... Type of Construction: No. Bedrooms .... .. �• <br /> /dOU <br /> Addition ... .................................................... Septic Tank Size Gals. .Z .. . ..... � < —i Q-): <br /> ....... <br /> Sanitary ..X... Size .............. ft. x .............. ft. I`foC ,. ,u, —O i <br /> F i l l i ng�G rad i ng ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> ....................... <br /> Soil Type ......................... .......... r -� <br /> Moving .......... Area .................... off; <br /> Mobile Home Slope ............................... .......... ti <br /> Privy ...,..,,.. 3. Use (describe exactly, 1 -family Pere. Rate ........................ .......... <br /> x <br /> Well .......... home, garage, motel, etc.) Dry Well ....... <br /> Subdivision .................................................... Seepage Trench ....... �1.. ZN: <br /> .......... .................................................... <br /> D <br /> Camping Unit .... Privy .. ...... m <br /> Seepage Bed <br /> --------------------------------- ----- ------ --- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be. sketched in Fig. A. Inclu le road r <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwcy inter- [ o; <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection- CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : p' <br /> --------------------------------_—_____--_-------------_____----_—_ --- <br /> 5. Lot Size: Fig. A. 6. Location: :k <br /> ................ ft. x .............. ft. — ............................... sq.ft. .......................................................................... ? e t :\ <br /> an <br /> :\ n <br /> N o <br /> 0 <br /> 90/5-_671 6200 <br /> 0 <br /> v <br /> M Nrne .y o' <br /> EA a F <br /> Z C) 5 Dn rn <br /> o n an n 3 <br /> s —i <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ................................................................................................................................................................. ....... m� � � .�:- � <br /> ......................................................................................................... <br /> ................. . . . .................... ....... uu' rn u <br /> T <br /> Inspection Date m <br /> ZoningAd Istrator '.�-/: 8 0 0 B Fn <br /> in <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures i ivolving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolatuo i 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 of specifications shall not be made without approval of line Zoning Administratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />