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Burnett County Office of Zoning Administrator 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. o <br /> TO Th- 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 he done in accordance with the requirements of the Burnett County Land Use m m iQ1't <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> .......... J 7e ... .... . .... ............................ _ <br /> N <br /> ... .......................... <br /> ....................................... o <br /> OWNER (please print) CONTRACTOR or SU RVEVOR ZD <br /> or AGENT a <br /> ............................... ........... ............... .....................................................................I...................... <br /> TIf ice. <br /> .....1........................ . . <br /> ADDRESS �sADDRESS m <br /> 2g . ...... . ................................................................................. <br /> �.... . ... .. ................... .... . ... <br /> ......_... . . <br /> ADDRES?!S . ..... .t ..... `j/ ADDRESS \ <br /> . e/Gtz-5s3-SsoG...... . .......................................................................................... <br /> PHONE <br /> HONE <br /> .......... <br /> ........................................................................................... <br /> . .............................................................................. \ <br /> PLUMBER WELL.. DRILLER : C <br /> .A..D..DRES.........S............................................................................. _. <br /> ADDRESS n o <br /> 0 <br /> PHONE PHONE Z 17 <br /> DESCRIPTION o <br /> 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms : o <br /> New Building No. Bedrooms .......... <br /> ,......... Type of Construction: Septic Tank Size Gals. .......... s <br /> Addition .......... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. <br /> .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ............................ ...... Soil Type ..................... r <br /> s o <br /> Grading ........I. Slope .......................................... <br /> Mobile Home y, y Perc. Rate ................................... <br /> r <br /> 3. Use (describe exact) 1 -family <br /> Priv home,garage, motel, etc.) Dry Well <br /> Privy Seepage Trench .......... <br /> Well .......... <br /> .......... .................................................... Privy <br /> Subdivision .................................................... Seepage Bed .......... M <br /> Camping Unit ------------------ <br /> ----------------------------------------------------- <br /> C <br /> Location of proposed st ructurrs and existing structures, well, sewage systems, roads,etc,should be sketched in Fig. A- Include road 'p Q <br /> C <br /> setback, side and hack Yard dimension and location and setback from all bodies of water. If property is located at a highway inter- N <br /> section, show the 'intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING W �, <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o O <br /> -------- — <br /> ---------------------- -------- n <br /> -------------------------- . <br /> 5. Lot Size: Fig. A. 6. Location: <br /> fS <br /> 2G>'?...... ft. x ft. — ............................... sq.ft. <br /> ............................................................................... :U <br /> 01 <br /> Application for land use (6 month period) <br /> / <br /> Camping Permit from to <br /> to // � ov o <br /> (date) <br /> (date) <br /> o ) <br /> u <br /> N -F <br /> o <br /> 0 <br /> r <br /> -o <br /> c.: T <br /> y <br /> Z r .� <br /> z <br /> � cnr �� NWz <br /> ry C N _. ry j C N <br /> LD yj Ci CJ < — _ $ <br /> LD, NC< — ' a <br /> C <br /> o � 3 <br /> p <br /> o <br /> Signature of Owner or gent Date i <br /> X <br /> p/7 �! v <br /> RemarksS.Gt,).. Q/t!.[. ,../.. ...T..!..Z!/�r;S�.................................................................................... <br /> !.Eo� <br /> ............................................................................//.................. ../J.........`.................................................. tL� j T <br /> Inspection Date .../�-....../.. ............. i I° . 0 m <br /> CD' <br /> 0 <br /> 0 <br /> ....................................... . ...�cJ � 0000tn <br /> Zoning Administrator <br /> NOTE'. A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac.ilitn" <br /> before construction can beglrl. In the GBSe of sewerage dlsposal systems, a copy of the percolatlon test must he attached to <br /> this application before a permit will ue issued. Do not purchase Or install a saHOrl [ink, dO d111 plural bing or strait ai V Ituild- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation oY any of the Intorm arz i� co�we f 6era- <br /> with 15 SEWER to SYSTiEM SIHAgLeL inplan <br /> nBE rCOVERED UNTILINSPECTEDIINtSPECTEeDw BY THIS OFFICEANDfile <br /> AND APPROVED. ato <br />