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Burnett County Office of Zoning Administrator Iv ;F "gg� <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 '� q <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 ofthe StgteofWisconsin. <br /> -P r' ..�. G. 4. — % .n <br /> . . . . ..................... .h..„.... .. .r.................... ............................................................................................ <br /> OWNER (Please print) CONTRACTOR or SURVEYOR or AGENT <br /> ..C3.............................................................. . . . . . ................................................................................. d t� <br /> ADDRESS t p ADDRESS ` <br /> 8.P.NI.K...Q........ ................... ... ..8. ...1.................. . . . . . . . ............................................................................. is <br /> ADDRESS ADDRESS :� .' <br /> �JJ >> ( ) io <br /> PHONE.....�.1. .:.�i..%.y?... .. ... .✓.f.......................... PHONE <br /> ............................................................................................ <br /> ........................................................................................... <br /> . ...... . .. . ....................................................................... 17Q <br /> PLUMBER WELL DRILLER <br /> O ' <br /> AODR ESS ADDRESS <br /> � o <br /> ........................................................................................... . . .................................................................................... ZS <br /> 1 . <br /> PHONE PHON.... E Z <br /> DESCRIPTION 4. Sanitary Facilities: ro— o iS <br /> 1. Work: 2. New Building Details No. Bathrooms - o <br /> e?-.. <br /> New Building Type of Constr�on: No. Bedrooms •••• •• <br /> Addition _....•._.;t�•X(••;• Septic Tank Size Gals. ......... <br /> T <br /> �............... C) <br /> Sanitsry Size .............. ft. x .............. ft. <br /> Flllin (Gradin ' 4a. Absorption Field Site: <br /> g 9 .......... Height............. Stories ............... p <br /> Moving .......... Area Soil Type .................................... w r <br /> Mobile Home Slope .......................................... ;.Q <br /> .......... <br /> Privy Perc. Rate ................................... <br /> .......... 3. Use (describe exact) 1 •family <br /> Well .......... home,garage,motel, a Dry Well .......... <br /> subdivisionSeepage Trench Z <br /> ,,,.,,,,,, i <br /> .......... O <br /> .................................................... Priv <br /> CampingUnit .......... .................................................... y ......... rF :� <br /> Seepage Bed .,I.�. �"7 ;oQ a <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. `(1j <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. = <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _________ _ 1 t <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... i <br /> o <br /> n <br /> �o <br /> O ±__0 <br /> O <br /> f <br /> 1 <br /> 0 <br /> T wI <br /> m Q\ <br /> r <br /> a <br /> (0Mdiu > mm -0 <br /> m_ �n < -' nm as y <br /> H mp <br /> rr� yn ' <br /> O n ; m <br /> on <br /> 1 m <br /> ��......... ........................................................ 7. ..a..1.. ..$. ........ x �, o <br /> Signature f Owner or Agent Date ' <br /> r'b <br /> Remarks .. �2r ��':: :`.::.- .. <br /> m •� <br /> N <br /> O p <br /> .......................................................................................................... .... ................................... .. . <br /> ....................... <br /> '7 7 � � N1N .� iN � <br /> Inspection Date ..Z......`....:...................... .... . ../,,;. .. ... .......... u, u' o o v, m <br /> 5 1 �CLI. m <br /> Zoning Administra r 8 8 8 8 8 8 0) <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 />