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I <br /> Burnett County Office of Zoning Administrator �' e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3 E01) <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ind 'Zy}Z 0 '� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he ,: t 'C"3 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> regulationsof th State of Wisconsin. - <br /> ...Cat <br /> I1 ....��a.t '?!eL/..................................... ...... .......................................................... ..... <br /> . . . ...... . . ... <br /> OWNER (please print) CONTRACTOR or..SURVEYOR or AGENT ; <br /> , Q.X....�:5........................................................... ...................................................................................... ..... <br /> ADDRESS ADDRESS <br /> re�er� ��P3 <br /> ADDRESS ADDRESSC��-- ' <br /> ........................................................................................... .P..H..O.....E ........................................—............ —................ ...... <br /> PHONE N <br /> .. <br /> PWMBER WELL DRILLER - <br /> . 3. ..................................................................................... ...... o _ <br /> ADDRESS ADDRESS 0 <br /> . . . . ............................................................................. ...... o ' <br /> PHONE PHONEZ N r :�_ <br /> DESCRIPTION 4. Sanitary Facilities: ° o » '•�- <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •" ' "' '� c - <br /> New Building . Type of Construction: No. Bedrooms ... ..... �- <br /> .......... i <br /> Addition ... Septic Tank Size Gals. /,. <br /> Sanitary ✓ Size .s�S ft. x • <br /> ...5:?�5... ft. •" •'•'•' <br /> .... . . .. .. . <br /> •••••••••• 4a. Absorption Field Site: '4—: ' <br /> Filling/Grading .......... Height. .. ...... Stories ............... • p <br /> Moving Area ............................... . . . ... Soil Type ............................. ...... r o <br /> Mobile Home .......... Slope ..............................,.... ...... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............1....(.f!!.h... ...... <br /> Well .......... home,garage, motel,etc.) Dry Well ... ...... 2 • <br /> Seepage Trench <br /> Subdivision .......... ......�. Q (/1 .�..1...... ... ...... 0 o p; <br /> Camping Unit .......... ....... Privy ... <br /> .......... ........... .. c <br /> Seepage Bed ..... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :,� ; Q <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at ,. �a <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 � <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... ....... <br /> D mf <br /> �1 ry <br /> n <br /> N N : p' <br /> J <br /> » 0 <br /> F <br /> V ( J <br /> �m <br /> m <br /> �O <br /> 31. � <br /> N <br /> a <br /> m c oNi rn mcg � <br /> od4Q o n <br /> T N o m 5 <br /> o < m 5 <br /> N <br /> Z^.o D -i <br /> o c m <br /> m <br /> c <br /> A : rn <br /> Signature of Q w n a r or Agent Date c <br /> Remarks .... ......................................................................................................................... .... m `. <br /> u <br /> O : <br /> .. 3...................... ?......... . Wig : . . n <br /> Inspection Date — � tk� N m N P P - m <br /> Zoning Administr or d'm 88 8 8 0 0 (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities 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 beer 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 AP ROVED. <br />