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Burnett Gounty Office of Zoning Administrator �' o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the $ c W <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 `8 <br /> regulations of the State of Wisconsin. » n <br /> Robert„B _ .3 <br /> . . . . .ehan.. ......Jr.................................................. . ............................................ .... � A <br /> OWNER (please print) <br /> CONTRACTOR or SURVEYOR or AGENT :m m <br /> :0 <br /> O <br /> .. ......B.M..393................................................................ ....................................................................................... .... d :o <br /> ADDRESS ADDRESS <br /> :cr <br /> ...........vf�4.st.e r..,...WX.....S 4.a.4.2...................................... . . . . .. ............................................................................ .... :M <br /> ;z <br /> ADDRESS ADDRESS <br /> .... ............................................... ...................................................................................... ..... <br /> PHONE PHONE <br /> ...........9ox.!ri.....5!re.n,...WZ.....5Ya.72.......................... ............................................................................... ..... <br /> PLUMBER WELL DRILLERC. <br /> ...........7.15.,3.4.9-.5533.................................................... <br /> v <br /> ADDRESS ADDRESS n O <br /> VO <br /> . . . ................................................................................... . ............................................................................. ..... <br /> PHONE PHON........E Z r <br /> DESCRIPTION 4. Sanitary Facilities: P 8 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details "' <br /> New Building .......... Type of Construction: No. Bedrooms <br /> Addition .......... .................................................... Septic Tank Size Gals. < <br /> Sanitary X"" Size .............. ft. x .............. ft. .... ..... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ...........................I.. ..... c i <br /> Mobile Home Slope .................................... ..... O <br /> .......... ' <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ............................. ..... W r <br /> Well .......... home,garage, motel, etc.) Dry Well .... ..... _ <br /> Subdivision Seepage Trench o <br /> .......... <br /> :N <br /> Camping UnitriVy .... ..... a w <br /> .......... .................................................... <br /> Seepage Bed : 1 : :in <br /> ------------------------------------------------------------ <br /> ----__ ____________________ <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locatf d at <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. — <br /> _ ; <br /> 5. Lot Size: Fig. A. 6. Location: 1 M <br /> ................ ft. x .............. ft. — sq.ft. ; <br /> ............................... ........................................................................ ...... <br /> W <br /> N O <br /> O <br /> � tm <br /> _.O 77 <br /> 5 � o <br /> m � <br /> (D V <br /> roc <br /> fv rA m LJ <br /> SEE STATE APPROVED PLAN ? o <br /> m <br /> t <br /> r e <br /> A <br /> 70 � <br /> 1 <br /> v : N 0to to <br /> n �a < Mon — — m <br /> m Na•< —" n- m nny <br /> O fR O O DIm <br /> O ; <br /> O <br /> Signature of Owner or Agent Date <br /> Ti w <br /> Remarks <br /> N <br /> 8 : 8 <br /> ............................................................................................................. ..... .............. .. .... m <br /> // N Do N N m <br /> Inspection Date ....................................... ....L... . ..... ✓..`�N� 7............. v, cn v, o o b m <br /> Hing Administrator o $ g $ o o fA <br /> NOTE: A preliminary site inspection must be made and site a 6 roval granted on all structures involving sanitary ta<ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 specifications 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 />