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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. r c <br /> Rom........h.�.iw.i;kn.......................................... .....s..1rJt-rr�.....tP...t.?-)(..CAw........C.dw�ftyox...f.�. <br /> OWNER (please print) ` CONTRACTOR or SURVEYOR or AGENT 1 (p! <br /> .... a�.;........1.,.o.J..t1 .....�.a.tt1.....�d- ....11`�...a,......A.]Q.x......a?.p.�1.......rY <br /> ADDRESS , ADDRESS S T$0.K <br /> 4+.�sk. .l.... .o.y2a ........$.....�? ...... . .....................................................I......................... 3 <br /> . 2 0. ........ <br /> ADDRESS ADDRESS _ <br /> ................................................................................... .............................................. 1 jr <br /> .............................................. <br /> PHONE PHONE C'0 •„[ <br /> ..-.`�r.n 9.................................. .......a5..-...........�v..S.J...g.!......:5................................. <br /> PLU BER WELL DRILLER < <br /> ADDRESS ADDRESS n O <br /> ....... <br /> ......................................................—............................—.... 3 ;.: <br /> PHONE PHONE Z » r <br /> DESCRIPTION 4. Sanitary Facilities: ° o » i p <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••• •"•' ` 0 ? } <br /> New Building ..X.... Type of Construction: No. Bedrooms ..... R ` <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ...�... , ft. x .....7. .. ft. .......... i i <br /> Filling/Grading .......... Height... ..... Stories_.f�l f 4a. Absorption Field Site: rn fvz <br /> Moving Area �..-F.�...Sy_.� c.•........ Soil Type .................................... P 1 F <br /> .......... ... 1 <br /> MODIIs Home Slope .......................................... <br /> .......... <br /> Privy 3. Use (describe exactly,'1 •family Perc. Rate ................................... <br /> well ,.,,., „ home,garage, motel, etc.) Dry Well ...I...... ' n <br /> Subdivision .......... �. .C.0.f... .. .. rbl. �...... Seepage Trench .......... o i V ' `: <br /> Camping Unit .......... . . '.�. ..... '�. . � .. . Privy .......... .'Os <br /> .,. ......... <br /> _,• <br /> Seepage Bed .......... i i 8— <br /> ------------------------ -------------------------------- <br /> A <br /> W P <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at y <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 11��` •� N 1t <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----- ------------------------------------------- .0 i <br /> S. Lot Size: Fig. A. 6. LRcati� 1 - <br /> \0.0....... ft. x .630... ft. — ...�.�.A.�?D sq.ft. .Gas.. ......41..f�or.�.....�... . �.LQ...L0....01\ : t i` 5 '. <br /> .3 p o {� <br /> r.veu. D ltj ry •_ _ \ JUL Q.CGCS$ �l6ad � :r '.f so <br /> IJJpp+`"n G1\mac. CO. N I O <br /> 03 <br /> Ir 1-w�e_ JM,r2 3' A ? �-- <br /> 1 <br /> J <br /> jt�3 <br /> cl T <br /> fr✓��� z <br /> 3D 1 « tsr :� 0 0r- > Mm <br /> m e . m m 0 c c lF' S y5 1! �cr< 0 D m a s 9 <br /> m c <br /> Zoo �c m � D . 1 <br /> » a_ : M <br /> v n o <br /> m c C <br /> . tRn �u..... n <br /> o <br /> ........ ..'.. ' <br /> c} .. . <br /> t. <br /> Si u Owner or Agent Date ' <br /> g : <br /> N . <br /> Remarks ......................................................................................................................................................................... m;. <br /> N W N <br /> n <br /> Inspection Date ....................................... O: u N N O O m <br /> Zonin dministrator g g g g gN y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 been 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 APPROVED. <br />