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Burnett County Office of Zoning Administrator 0 o <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 located as — o ,$- <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use C <br /> �X — regulations of the State of Wis,fonsin. 3 a ? Y <br /> O,r6/c�+�ance, Sanitation Code, and with all other applicable County Ordinances and the laws and reg 1 <br /> ..... ........... . ......................................................... .. ........ ..................................... ...... ........ { ........ m <br /> OWNER (pl ase print) CONTRACTOR or SURVEYOR or AGENT ! m m <br /> ....... . . . . . . d�:.......1 'L..cu-t'�� <br /> ................................... a <br /> ADDRESS............................................................................ . . .. I......... <br /> ADD ESS <br /> ADDRESS <br /> Aro. pxa:: : ,....w� <br /> . ....:`?1.. R> ............ ......... , <br /> ........................................................................................... . ........E........................................................................ ......... <br /> PHONE PHON <br /> ........................................................................................... . .. ......... ............... <br /> ...... <br /> ......... <br /> ....... <br /> ...... <br /> .................. ......... <br /> PLUMBER WELL.. .. DRILLE.... R <br /> ............................................................................... ........... . <br /> . ADDRESS..................................................................{....,.... <br /> ADDRESS as ' <br /> I n o y <br /> PHONEPHONE........................................Y.............................1......... <br /> DESCRIPTION o H <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2. New Building Details No. Bathrooms I <br /> New Building .......... Type of Construction: No. Bedrooms ll......... [ a 1 '. <br /> Admtion .......... .............................I...................... Septic Tank Size Gals. <br /> Sanitary Size ft. x ft. {......••• <br /> Filling/Grading „ ,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: Ii .'• <br /> Moving .......... Area ........................................... Soil Type ..........................I......... I I r <br /> Mobile Home Slope .............................. o <br /> .......... <br /> Privy .,,....... 3. Use (describe exactly, 1 -family Perc. Rate ......................... ......... i <br /> Well ........., home,garage, motel, etc.) Dry Well ......... E i <br /> Subdivision „ ,,,,.... Seepage Trench <br /> ... Priv .... <br /> ........ ......................................... �.... <br /> Camping Unit y �......._ <br /> Seepage BedJ <br /> ________________________________________ —I--- .N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be, sketched in Fig. A. Ini road e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a hlghwa inter- a <br /> section, show the Intersecting highways and the setbacks required along them and at the Intersection_ CLEARLY LABEL EXI TING 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---__---_-_________ ________________________________________ ______ __._ : 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ........................................................... ......... ......... <br /> 3 <br /> vl <br /> 0 <br /> � o <br /> 15 <br /> :4— <br /> :r,, . <br /> X r— M : 0 m Z <br /> c c . <br /> m a <br /> d _ n W <br /> <; as m <br /> c M <br /> y <br /> Z H. n <br /> o 5! 4 aro M <br /> �ch —i <br /> � <br /> m.. ”{. c. ............ o p <br /> Signature of Owner or Agent D�at. e <br /> O <br /> Remarks ................................................................................................. m X m <br /> ..........................................................................................................................................................................!. <br /> ........... ..... ........ ....... ...... ...... ..... . ..... . .... ...... .... . . .... .... <br /> .711 <br /> g d <br /> Inspection Date .. .... ..... ............ .. . � <br /> Zoning A m n/Is..... / / U N fA N m <br /> r <br /> I y Lc'fYl II c� o D o m <br /> NOTE: A preliminary site inspection must be made and site approval granted On all structures in�olving sanitary facilitwx <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 riot purchase or install a septic tank, do any pluchhing or start any build- <br /> ing until a permit has been issued. A permit may be revoker] If misrepresentation of any of the 'mfc�rmation conveyed here <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistratul . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE FIND APPROVED. <br />