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&-79 <br /> Burnett County Office of Zoning Administrator v 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 3 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a �} <br /> n <br /> N�! iW. .t. ...... �... Pl .rt...� ............ ............................................................................................ <br /> 0 <br /> OWNER please print) \ CONTRACTOR or SURVEYOR or AGENT 3_ <br /> :11 m <br /> L.. .1�......... ?...(............................................ .......................................................................................... d <br /> ADDRESS ADDRESS = � <br /> ........................................................................................... ............................................................................................ h <br /> '3 <br /> ADDRESS ADDRESS V` c•� <br /> i 3^� <br /> .................. ..................-.................................... ............................................................................................ 60 �f <br /> PHO 'E PHONE '� 4 <br /> .. ...... ................................................................. . . . ..................................................................................... <br /> P U BER WELL DRILLER <br /> ........................................................................................... .AD......DRESS.... -S' ....... .. <br /> .. ................................................................. <br /> ADDRESS n 0 <br /> n O <br /> ........................................................................................... .PHON.... ..- ........................................Y............:.......................... o .: <br /> PHONE E Z H Q <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> """"" <br /> 1. Work: 2. New Building Details No. Bathrooms - <br /> New Building ........., Type Qf Constwt = n: No. Bedrooms .......... f§ <br /> Addition Septic Tank Size Gals. .......... �� <br /> Sanitary ...x. Size .............. ft. x .............. ft. ........,. i <br /> FillinglGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Type ...................... . .. .. <br /> .......... Area ........................... ............... <br /> .. . .... .. <br /> 0 <br /> MobileHome Slope .......................................... ., <br /> .......... d <br /> Privy ,,,.,,.... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Seepage Trench <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision <br /> .......... thh \\ <br /> Camping Unit ........ .................................................... Privy <br /> .................................................... <br /> Seepage Bed <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- O- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING /r <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �_/ O <br /> ---------------------___-_-------_____-___----------___.-__----- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq.ft. ............................................................................... _I <br /> V o <br /> m <br /> N � O <br /> O 7 <br /> -71 <br /> 7 <br /> � V <br /> O <br /> j <br /> S <br /> Z '�! <br /> O <br /> d <br /> m <br /> J <br /> n t v w m Z <br /> m � w <br /> m H3 cr <br /> to <br /> C .G ro c T <br /> m - rt <br /> Z O O n <br /> rr <br /> O � <br /> O <br /> rr <br /> .... ... ......... ....... . ......................................... ...................................... o : C <br /> Signet re of Own r or Agent Date - - - <br /> X 7 <br /> Remarks .L. �..j m rr <br /> ................................................................................................. fA <br /> ....�.l.............................................................................`.........�.,.............[. .......A...^......,..{........x..•..... <br /> �7 ��� ygn o c0io rt <br /> Inspection Date V�� Ztor- <br /> NOTE: A preliminary site inspection must be made and site approval granted mrall Involving sawtalv T <br /> far", )tics <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 Adm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />