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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3• -` <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of Wisconsin. a '•,{+� Q <br /> l'..4..4...^......Sc9.aC�."rS... 4 fi . M <br /> OWNER (please print) CONTRACTOR or SURVEVO or AGENT o <br /> Q.. .x....L.3.. '......................................................... ..................................................................................... ...... d � � <br /> ADDRESS ADDRESS 1 ;� <br /> X4 .1 h .a... ............ Su <br /> ..................................................................... . <br /> ADDRESS ADDRESS <br /> t i i <br /> .................. ........................................................................ . ......................................................................... ...... <br /> PHONE `� 'P-H-0—N-E-............ <br /> K.Asio.'rl..t.4.:T..................................................... ...... . .. . ................................................................ ...... i l <br /> PLUMBER WELL DRILLER <br /> :G <br /> 'd <br /> ........................................................................................... •O <br /> ADDRESS AD <br /> OR ESS » G <br /> ......................................--..............................................- . .............................................................................. ...... O <br /> :h <br /> PHONE P..H..O..NE Z <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: 2. New Building Details No. Bathrooms •" """ i 00 <br /> New Building Type of Construction: No. Bedrooms ... .. �" R (� <br /> C-ny,.��. Septic Tank Size Gals. ... ..... �\ <br /> Addition .. ............/....................................... < <br /> i <br /> Sanitary ... .... Size ..Pl^ ..Q ... ft. x ...3.n.... ft. <br /> Filling/Grading .......... Height.....P..... Stories ..!.1 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ............................. ...... i <br /> ........................................ o <br /> Mobile Home Slope ................................... ...... v .. <br /> .......... Perc. Rate ................... i <br /> Privy ,,........ 3. Use (describe exactly 1 -famil '••••••" •"•'• 0 <br /> Well .......... home,garage, motel, etc. Dry Well ... ...... m �V <br /> subdivisionSeepage Trench o <br /> Camping Unit .......... ....... ....I....................................... Privy <br /> Seepage Bed <br /> ------------------------------------------------------------------- -- nG2 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. : 1"_ C C ( l <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local id at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. r <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ___________________________________________________________________ __ � <br /> 5. Lot Size: Fig. A. 6. Location: '—� 1 <br /> E <br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... ....... <br /> rb <br /> N O <br /> O 7 <br /> O <br /> ao' vo 0 0 <br /> � rf <br /> e <br /> • �'� • 4Y l� o -� <br /> d <br /> 3 <br /> Z <br /> M a—0 0 0 C a <br /> oho < > > n = _. m <br /> m �n< nm na :A <br /> c <br /> D - <br /> 1 <br /> o c M <br /> O : D <br /> c <br /> m <br /> ....................................... ...................................... <br /> Signature o Owner o gent Date g G <br /> Remarks 6� . <br /> : <br /> ................................. ... ................. ... .................. . <br /> ...... ...............I................. .... <br /> Inspection Date �1.....�! — ... g g g g g m <br /> M <br /> ZoningAdministrator o N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl ation 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 />