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Burnett County Office of Zoning Administrator o o v <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 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 m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> :\ Y <br /> (.c1.7..L.(. .r........ .a.a..................................... ................................................... N o <br /> m <br /> .o <br /> OWNER (please print) _ CONTRACTOR or SURVEYOR or AGENT m 10 <br /> �.. ... ....... <br /> ��y6 1owA y✓E a <br /> ........................ ....... ............................... <br /> ............ .................. ............................................................................................ <br /> ADDRESS C , •rj' if �q ADDRESS c, <br /> ST.Pwv.............../ L.ry.!t........... ............................................................................................ <br /> � <br /> ADDRESS ADDRESS \ <br /> PIEDp} PHONE ;,� ;^U <br /> r5......N...� .fir... ...s.................................................. ............................................................................................ r <br /> PLUMBER WELL DRILLER <br /> eO <br /> ........................................................................................... ............................................................................................ O O <br /> ADDRESS ADDRESS m 0 <br /> zin <br /> G <br /> ........................................................................................... ............................................................................................ O .: <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: No. Bathrooms u� -0 <br /> 2. New Building Details �p o <br /> New Building .......... Type of ConstrGcfNo. Bedrooms oDe�b ii <br /> 4i�' <br /> Addition J Septic Tank Size Gals. .......... i <br /> Sanitary Size ft. x ......a..... ft. <br /> FillinglGrading .......... Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ...................... ............. o 0 <br /> i <br /> Mobile Home Slope .......................................... .1 •+ <br /> Pend. Rate ............................I...... rn <br /> Privy .......... 3. Use (describe exactly, -family <br /> wellDry Well .......... A :0 <br /> .......... home,garage, motel,etc.) <br /> Subdivision .......... Seepage Trench .......... u <br /> .................................................... F <br /> Camping UnitPrIVy .......... :O. <br /> .......... .................................................... Seepage Bed ..........---------------------------------------------------------------------- <br /> w <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ip o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 6 <br /> ................ ft. x .............. ft. — ............................... sq.ft. to <br /> G i3 <br /> N A .o o. <br /> o n <br /> � 9u <br /> O 'Q <br /> �O O <br /> � s <br /> h i T <br /> A <br /> Z <br /> O <br /> m <br /> W z <br /> Cr < a <br /> m <br /> bi5i: m ysm <br /> 0 0 � adz <br /> • v, - m 3 <br /> kA o 1 <br /> tv <br /> (a....../.6 �G p <br /> ............. ................................................ o c <br /> Signature of 0 er or Agent Date <br /> Remarks .... ... ...... .. .......................................................................................................................................... � ; <br /> m <br /> fn <br /> ............................................C...................................................... ... 1 . . . . <br /> Inspection Date . z�� -g-Ad--7n <br /> N �' � '��" m <br /> / ..................... ....... <br /> Zoning Ad nistrator <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 septictank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit ri be revoked if misrepresentation of any. of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not Ife made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />