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G`t1? �fD9it�, <br /> Burnett County Office of Zoning Administrator d J o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < 7 '. <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c Ordinance, Sanitation Code, and with all other applicable Count Ordinances and the laws and regulations of the State of Wisconsin. 3 a i� i <br /> Ord PP Y 9 <br /> 0 to <br /> ... ... ........... .......................................... . ........................................... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> a <br /> . ..�.. ........Wgs11.Q. .... ............... <br /> ............................................................................................ a <br /> A RESS ADDRESS <br /> m <br /> . .�.5.. �...(� �.......!Y�.n...>........s 53..3.7.. ..... . . . . . - - <br /> ADDRESSADDRESS............................................................................ <br /> PHOyd')! PHONE <br /> . . . ..................... ........................................ . . . ..................................................................................... .i � <br /> PLUMBER WELL DRILLER <br /> ..... . .................................................................................. ...R-ES-....................................... ... .... .. G� �.......... 1 _� <br /> ADDRESS ADD. . RESS <br /> l m <br /> n o iry <br /> .................... <br /> ........................................................................................... .................................................................:...... o ,» <br /> PHONE PHONE Z :Z <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: 2. New BuildingDetails No. Bathrooms ... ...... v <br /> i� <br /> New Building ...... ,,, Type of Co tr coon: No. Bedrooms ....Lo <br /> .... <br /> Addition P <br /> tCl Se tic Tank Size Gals. .... <br /> .......... '�jL. ...... ...... ��, <br /> Sanitary ... Size .............. it. x/,............. ft. ..........U i( f( <br /> FillingiGrading ,.,,,,..,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... � r <br /> Mobile Home .......... Slope .......................................... <br /> Privy ........ 3. Use (describe exactly, -fa Pere. Rate ................................... <br /> W <br /> Well .......... home,garage, motel, et � Dry Well .......... I <br /> Vw <br /> Subdivision Seepage Trench .......... T <br /> Camping Unit ,........, Privy .......... <br /> ...... — Seepage Bed �- <br /> ____________________ _____________ ________ _______ __ __________ ___ r 'N <br /> Location of proposed structures and existing structures,well, sewage systems, roads eta.,should be, sketched in Fig Ae r <br /> - Includoad °�� c: <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter a <br /> section, show the interct <br /> secting highways and the setbacks required along them and at the 'interseion. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> _----. ------------------------_. <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .......... .. fI. ............................... sq. ft. .............................................................................. <br /> , <br /> r <br /> t o <br /> f <br /> 0 <br /> s <br /> ✓� jn n <br /> �Uad %;t? <br /> e Z <br /> o <br /> 'YS` vY' m <br /> SO <br /> W <br /> U <br /> r ak FJ <br /> a <br /> N C : <br /> m — m <br /> Ul < q C n <br /> � . � . <br /> Z ceo > a <br /> o _ M n� <br /> �o <br /> Signature of her or Agent Date <br /> ET C <br /> X 7 <br /> � „ : n <br /> Remark//..... .. ... "..... .rf1.7f:.'`. ."........................................................................................................................... m : C <br /> F» <br /> ........................................................................................................................................................................................ — <br /> ......................................................,.../....................................................... ... .............. .......... <br /> Inspection Date .% ."..c!Z/ ` ...P.... ..... ...... ........... ...................................I....... o U n <br /> n <br /> Zonin Administrator : 8 8 S 8 S u <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facllitiec <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 Adm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />