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Burnett County Office of Zoning Administrator o <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 nd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws ind 3 `a <br /> regulations of the State of Wisconsin. F; <br /> �Iytc ..........h..........,�.c,m...�.� .�........... .................................................................. ..... <br /> . . . ...... . . . . <br /> OWNER IPiease print)) CONTRACTOR or SURVEYOR or AGENT <br /> /..A.d..f.......... ley w...0� ..........f.Z.d....................... . . ...... . ......................................................................... ..... d <br /> e <br /> ADDRESS y J ,y� ADDRESS <br /> /,/............. !.......... S .Y. .1�.. ...................................................................................... ..... ((l <br /> ADDRESS ADDRESS vI <br /> .......................................................................................... . .......................................................................... ..... <br /> PHONE . <br /> PHONE ) �/ / <br /> 1T e.T7�.r h..........�Y....!T%l.f...................... <br /> PLUMBER WELL DRILLER <br /> 4_1.........Jillr ............... . .............. S_SYf/,) <br /> . ...................................................................................... ..... o <br /> ADDRESS ADDRESS <br /> ................................................ ..... . . . <br /> PHONE PHONE Zr <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° <br /> 1. Work: No. Bathrooms v <br /> 2. New Building Details ••'• ""' � o ' <br /> Now Building No. Bedrooms <br /> .......... Type of Construction: ••• ••• ':� i <br /> Addition Septic Tank Size Gals. 'r.990 <br /> . <br /> .......... <br /> Sanitary ...�... Size .............. ft. x .............. ft. <br /> FiltingrGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> .......... Area ....................... . Soil Type .......................Moving . .................. ............. <br /> Mobile Home .......... Slope ................................... ...... o <br /> v " <br /> m <br /> Privy .......... 3. Use (describe exactly Perc. Rate ............................ . <br /> ,�1 -family �••• S <br /> Well .......... home,garage, motel,etc.) Dry Well ... . .... m <br /> Seepage Trench o i <br /> Subdivision -,-,,,,,,, ^' ^^^ <br /> ....................... ............................ ; <br /> Camping Unit .......... Privy ... . .... <br /> .................................................... p g <br /> See a e Bed ... ..... oL) i <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at f <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.. o' <br /> --_ <br /> 5. Lot Size: Fig. A. 6. Location::: <br /> ...3..7.v.. ft. x .... .6`�. ft. . ............................... sq.ft. ............xl✓.7.........i c D.'/............................. ...... C <br /> N �N <br /> O <br /> O 7 <br /> 7 <br /> E <br /> �s f <br /> � j <br /> Z c, <br /> O <br /> d <br /> �J <br /> M inrammn0 <br /> o �a < W n S. S. nI <br /> m �n� - mangy <br /> m y 3 <br /> 0 0�. : m � ro <br /> Zoo : 1 '� n -i <br /> a ' <br /> N a A <br /> n o p <br /> Signatur ne r Agent ate c <br /> U! <br /> T . <br /> Remarks .....................................................................................................................................................................'... <br /> w. H <br /> u <br /> .............................................................................................................. ..... ................ .... ..`............................... ... <br /> V 1 w n <br /> m <br /> Inspection Date ....................................... ..... ............... ...::... ............. ... ut v o o ut <br /> Zonin.9A inistrator 8 8 8 8 8 8 vmi <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac,�lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli 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 been 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 />