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N'Y (''CrrL( , <br /> Burnett County Office of Zoning Administrator 7 -- 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 n <br /> _ o <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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> 3. O <br /> ./..[7]��,) .......Il . <br /> ............................. .......................... J..l ........................................... <br /> OWNER (please print] r�r. lil /— CONTRACTOR or SURVEYOR or AGENT o. <br /> / tA <br /> A. .Crt.. )....... V...../. ...�...... G' ADDRESS............................................................................ <br /> ..... .... .... ............. <br /> ADDRESS.. J ADDRESS............................................................................ <br /> .53. :..;............. ...... ............................^�........... .............................. .... ...................................................... <br /> PHONE ` PHONE p ;� <br /> 'f�U Lfas .... .. �u <br /> PLUMBER WELL DRILLER q� ~0 <br /> i <br /> .... . .............................................................................. .......................................... S ' I p <br /> ADDRESS ADDRESS S L� cT n 00 .� <br /> . . .....�y.�.t...,f.......... O < <br /> P ovE PHONE Df5Ir N <br /> DESCRIPTION 4. Sanitary Facilities: S `-"'° o <br /> 1. Work: y 2. New Building Details No. Bathrooms .......... a. o <br /> New Building Type of nstruction: No. Bedrooms ... .... it <br /> Addition ,,,,,,,,,,,,��.,/` ' .................. Septic Tank Size Gals. ...... ... <br /> Sanitary Size ...ZuF... ft. x .�.;L..... ft. <br /> FillIng lGrading ,,,.., 4a. Absorption Field Site:,.. Height............. Stories ............... , <br /> Moving ........................................... <br /> .......... Area ........................................... <br /> Soil Type ...........................I........ : \ <br /> .( (oX �Q Slope - o <br /> Mobile Home r <br /> i <br /> Privy ,. 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> ........ <br /> Well „xhome,garage, motel, etc. Dry Well .......... <br /> Subdivision <br /> Seepage Trench "" <br /> I <br /> .......... <br /> Camping Unit .....,,,,, Privy <br /> SeepageBed---------------------------------------------------------------- <br /> location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched In Fig_ A. Include road <br /> I <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway Inter- o; <br /> section, show the Intersecting highways and the setbacks required along them and at the Intersection_ CLEARLY LABEL EXISTING :cl <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. .4 H <br /> U <br /> -------------------__---__--- o. <br /> 5. Lp Ize: eq Fig. A. 6. Location: <br /> .... ... ft. x .30..a.. ft — ............................... sq.ft. ................................... . <br /> m <br /> N C O <br /> A- <br /> �, €4 D <br /> >1 '" 70nit <br /> m <br /> �r',E O <br /> I r d <br /> m <br /> y7 (nr v o+ m Z <br /> n Q < m c m <br /> � aF <br /> N m m <br /> "O U1 <� <br /> z oo' m Dam <br /> m <br /> ...................................... Eto [ C <br /> Signature of Owner or Agent Date . . . — <br /> f .. � ; : m <br /> Remarks .. .....:. ........................................................................................................................................ <br /> e» <br /> .................................................. .. ............................................ — . . . <br /> T /T............................. .. ......................_........................... r u <br /> -z,a�! tG�c�c ............................................ O : . . : : : <br /> p.... ......................../ V....................... .... ............. .. ........ <br /> Inspection Date ....�. ..{..5_—. ............. ..... ..... .. ... ....... .............. . : 10: u a o o u m <br /> T <br /> . ........................... �" . <br /> Zoni Administrator 8 8 8 8 8 8 <br /> NOTE. A preliminary site inspection must be made and site approvol 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 />