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Burnett Cevnty Office of Zoning Administrator g' <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3 <br /> � " o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ndM <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he m <br /> # <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all oche applicable Countrdinance� and the laws nd 3 <br /> AP <br /> regulations of the State of Wisconsin. <br /> .eft ? ..... :. �eM...N® ..................... <br /> OWNER (plea»print) CONTRA TOf or SURVEY r AGENT <br /> !��... .. yH.. .. ... ...... ...................... ........ ......................... .....y...................... ..... d <br /> ADDRESS ' r / ADDRESS r/ <br /> . .o.<� �i�......,..� ?........r5�.......... .......�-Ae1.l...... .a....K....( j::.S.:........ ... ... ........ ) <br /> ADDRESS ADDRESS <br /> 11 <br /> ......................................... ............................. ............... . . . . ........... .:..... j ................................... f M <br /> O PHONE <br /> PH <br /> /........1., ...... <br /> ,Ta'.i3t Qq <br /> j . C <br /> PLUM ER � � / WELL DRILLER O <br /> lll '�?.�t... / . .. �:...... 5 ..................................................................................... ...... <br /> ADDRESS ADDRESS <br /> /// / ` 0 <br /> .............................. .[..: ....... ........(..............(..4......... ..................................................................................... ...... �\ <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: P 8 <br /> No. Bathrooms <br /> 1. Work: <br /> New Building ... 2. New Building Details ""' o i <br /> . Ty'e of ...ns ction: No. Bedrooms <br /> AddAdditionr� - (✓/,�,(qf�,••,- ,,, , Septic Tank Size Gals. ... ...... <br /> ......... G....:..0 . .... . . <br /> Sanitary .......... Size .�G.. .. ft. x �T '. ft. "' """ <br /> Filling/Grading .......... Height .... Stories .. . . .. 4a. Absorption Field Site: <br /> Moving .......... Area .. ... .. .. .F' Soil Type ............................. ...... c i <br /> Mobile Home .......... Slope ................................... ...... ,» <br /> Privy .......... 3. Use (describe exactly 1 -family Perc. Rate ............................ ...... <br /> n <br /> Well .......... hom�garage morel, etc.) Dry Well ... ...... m <br /> Subdivision �y/ /) Seepage Trench .......... o <br /> .......... /...Q�.(.... ........8 ............. i <br /> Privyc1 i <br /> Camping Unit .......... .l!1 ......�f�1..N1�............ Seepage Bed .......... x� <br /> In <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. —L ' g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at W i _ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 1 i <br /> ____ ____________--------------------------------- <br /> 5. <br /> ____________________________ _5. Lot Size: v Fig. A. 6. Location: / �}•� <br /> ��/I / ................ ........F—n.. .(.c.`a1.`.'r{... . . . i <br /> �.�... ft. x�.l...l.. ft. — �I D.... sq.ft. X'n <br /> N O <br /> o J <br /> O_ <br /> 7 <br /> O _ U <br /> o <br /> �1� �/ <br /> See w ?� <br /> -14o <br /> d <br /> N c N N CDi E. S. m <br /> o — _. m <br /> m Nam — m m a a y <br /> .o Co °1 c m 3 9 ; <br /> Z_O � D 1 <br /> PNS . Na ' <br /> 2 <br /> n o . 0 <br /> ' 0 - <br /> n : In <br /> Signature of Ow r Agent Date o <br /> T: N <br /> Remarks <br /> $ : $ <br /> N <br /> InspectionDate ....................................... ...... .... ...... ....... . ...... . ..................1..... . v, <br /> Zoning Admi rator I g g o $ g <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 beeri issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications 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 />