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Burnett County Office of Zoning Administr for fC � gig <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 `a <br /> regulationsof the Stateof Wisconsin. n is <br /> S .V6FYNIy >n " <br /> .....! u .................................... . I" <br /> OWNER IPleax print) CONTRACTOR or SURVEYOR or AGENT <br /> .. <br /> ADDDRDR ESS ADDRESS •01. I <br /> MPDS n� � s�f13 G <br /> ................................................................................ ..........................4...444.........4.................4..........4............ 4.....4 <br /> ADDRESS ADDRESS <br /> U� <br /> PHO //''--..((//.. {F-. .........................444.......................4 PHONE <br /> ...�!..I..Q�..'.1..�n..f .................................................................................... 4444... <br /> PLUMBER WELL DRILLER <br /> ...... ...... <br /> ........................................................................................... . .ADD.. .. R.... .............................................................. . <br /> ADDRESS _) f ^ !� ESS...... o <br /> 0 <br /> PHONE L�Z� �3�2— /Or�S3 —1A/ PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: I ° o » n' <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details 5 •• o <br /> Now Building X.. Type of Construction: No. Bedrooms <br /> 4444 <br /> Addition .......... F,r !;>ri..-..ti,- .,, ,.... ....• Septic Tank Size Gals, 4 444. ii . <br /> Sanitary Size ....�a.Q... ft. X .... ... ft. ••••• <br /> .�.. 4a. Absorption Field Site: <br /> Filling/Grading .......... Height............. Stories ............... e-�-- <br /> Moving .......... Area ..............4..4.4...4................. Soil Type .......... ... i r <br /> f <br /> Mobile Home Slope ................. �,.. / v » <br /> C o i <br /> . ... .. . ..... <br /> .......... Peic. Rate ............. v <br /> Privy ,,,,,,,,,, 3. Use (describe exactly 1 -family • •�• ••••� ••� <br /> Well home,garage, motel,a Dry Well �% .. m <br /> .......... / .. <br /> Seepage Trench z ' <br /> Subdivision ��� ��� o <br /> Camping Unit .......... ....................................................... Privy .... <br /> 4444 Seepage Bed .. ....... � <br /> ___________________________________________________________________ __ : IN <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi 1. A. <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. �` <-„ <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. \n i <br /> ___________________________________________________________________ <br /> __ I <br /> 5. Lot e: Fig. A. 6. Location: s :t• - <br /> i <br /> ..�........... ft. x .. ft. — ............................... sq.ft. ...................................................................... ....... :4-L <br /> Lj�K 6- <br /> P 0 <br /> " <br /> I se�b � o <br /> 1043 A5 eora f <br /> A+i - o <br /> iT <br /> i a <br /> T : <br /> 0 r. <br /> o <br /> o � <br /> 0 v &v - 00 nS. S to <br /> / T. "ci ' dm na y <br /> i✓err C,t_ m <br /> n ; y <br /> O <br /> x ! m <br /> .. . ... ..... 4444. ..... ......................................... ................ a................... A <br /> Signatu of w er o Agent Date o <br /> Remarks ..... m u. <br /> . ......... ........ ........... ........................................................................................................................... n <br /> M <br /> L E� <_ zQ { Zc g <br /> � N <br /> Inspection Date .0 .......... 9 ................... .... .... <br /> Zoni Administrator o 8 $ <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 appl cation 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 bee i 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 />