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Burnett County Office of Zoning Administrator on 13 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as 7 '6`n <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a V\ <br /> �bS�6dZMX1�d14Si§Z Doug Jiracek — '� <br /> ................... . 0 F <br /> s.......... ............ `m EES :� <br /> OWNER (please print) CONTRACTOR or SURVEYOR or, AGENT a \ [� <br /> 11009 Littl Ave. S. 'a ? E� <br /> ADDRESS.................. ................................................. .ADDRESS............................................................................ ;t7 <br /> .... <br /> Bloorningto , 55437 .0Q <br /> ........ . ............................. ............................................................................................ <br /> ADDRESS ADDRESS �� ;C� <br /> PHONE PHONE CID <br /> Daniels ............. 'o y � <br /> .................................................... <br /> PLUMBER WELL DRILLER <br /> Box..W.............Siren.,..W ....5487�................... �1 <br /> ADDRESS ADDRESS o <br /> ..........7.1.5:n463.-?3.33...................................................... <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: S ° <br /> 1. Work: - No. Bathrooms 1. <br /> 2. New Building Details 0 <br /> New Building .......... Type of Construction: No. Bedrooms 3......... o o `N <br /> Septic Tank Size Gals. .......... ! w <br /> Addition .................................................... H. Tank 2000 < R <br /> .......... <br /> Sanitary ..... ... Size ft. ft. """"" <br /> Fillip /Gradin9 .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> :cr <br /> Moving .......... Area .......................................... Soil Type .................................... i o _. <br /> C <br /> Mobile Home Slope .......................................... (1 <br /> j� <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... :: <br /> -I Dry Well """"" <br /> Well ,,,,,,,,,, home,garage, motel, etc.) `: <br /> Subdivision Seepage Trench .......... <br /> Camping Unit .......... .................................................... Privy .......... �. io <br /> Seepage Bed CM ino <br /> w N r <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 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING :� m > ` <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. P, 'a o <br /> t <br /> 5. Lot Size: Fig. A. 6. Location: ➢`' ' ��[ <br /> V i <br /> i <br /> ................ ft. x .............. ft. . ............................... sq.ft. <br /> u1^` M <br /> 'r <br /> yy O . <br /> SEE STATE APPROVED PLAN ` N <br /> Oil � 0 <br /> y <br /> Lti <br /> o <br /> w <br /> 1°I <br /> �1 ch - d !D Z <br /> n C' < m c F <br /> N EA a <br /> o Ch <' C <br /> M <br /> Z oo aa77 <br /> o 0 ae 3 <br /> yr - <br /> o <br /> / � O o 0 <br /> ;➢ m <br /> ............................................................ ...............................�.. i)j o p <br /> Signature of 7O/wner o Agent ' Date . <br /> Remarks4Y./..�y�...G . �' x . m� <br /> .............. .................. ...................... ....f 't ....:....................................................................... <br /> y.......... <br /> It <br /> .................... ............ .. .........................�...j ...: . .............................._ <br /> Inspection Date ........... .�.. ..5.. .... .GI:4?&.✓PP... ...1.. .... ......... ... ................ i o u o ren o a m <br /> Zoning A inistrator�✓ 8 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />