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on co r. <br /> Burnett County Office of Zoning Administra r Iv c <br /> 1 <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 t2 0 i <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m i�- <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. a <br /> BC... �- �'�✓sTy2Fi ' G-r/ H '� a' 9 <br /> ?2l...............................:....... .................. C..TT............................ .... ? 3 <br /> OWNER (please print) CONTRACTO or SURVEYOR or AGENT J o <br /> .................. ........ . <br /> y3 . .......s :.3 �:...5C ........ <br /> ....................... — <br /> ADDRESS ADDRESS o, � :�-- <br /> rn � .:...... ..........5Y.Y(v......... ............... .... <br /> ADDRESS <br /> -��........��1.. C� i7 .. ..'�. <br /> ..H6i4..�...................... .:.. �.......................... � �.3.:-....�.....!Z... .... ..�:... .6..'..Y....'1.............�c= � <br /> PHONE �a�.— [`,'O �(���� PHONE <br /> // <br /> .......1/ .ez,G( (rs......... ..-........................................ <br /> ................... . . <br /> PLUMBER WELL DRILLER <br /> ....... S i......... ......................................................... ...................................................................................... ..... E •� ' i <br /> ADDRESS ADDRESS C) <br /> n O <br /> ct <br /> ........................................................................................... . ............................................................................... ..... - O w :� <br /> PHONE P..H..O..NE 2 » r <br /> DESCRIPTION 4. Sanitary Facilities: ° o o `n <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details p T <br /> New Building ....X,, Type of Construction: No. Bedrooms ...e..... is R i <br /> Adawon .......... / „r 2,¢rv� ,Gtpi /,- i9 n6 SePtic Tank Size Gals. V <br /> SanitaryPol <br /> ..1K.... Size .. ..Y.... ft. x ..3..a2.... ft. .. . ... .� i <br /> Filling/Grading .......... Height..:?1e.. Stories .....2....... 4a. Absorption Field Site: O ;m <br /> Moving .......... Area Soil Type .............................. ..... i r <br /> MODIIs Home .......... Slope .................................... ..... ^ : <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............................. ..... <br /> Well .......... home,garage, motel etc.) Dry Well .. m <br /> Subdivision .......... .. .F. /rl.>.5 y /� Seepage Trench .... ..... o <br /> Camping Unit Privy ... : <br /> .................................................... DD <br /> Seepage Bed <br /> -------------------------------------------------- ---------- . .�f �y✓ ; <br /> CSLJJ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c r <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at 1. <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. U( ' o <br /> ____________________________________________________________________ _ t - <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq. ft. i� <br /> ......................................................................... . <br /> lerre4dicd It1 <br /> yL1-cO 0 <br /> P <br /> d <br /> 9) 1 D <br /> Z <br /> 111 D <br /> �Nr <br /> m m v m r D m m <br /> m Na < nm nag <br /> 90< °ic0 p' j3 <br /> mom . ya ' <br /> 2°Sa . M <br /> » oO <br /> � m : <br /> : <br /> ( Y �...... .... ... <br /> �//............ <br /> �� � <br /> .. .. ...... o <br /> Signat of Owner or Agent ��� I Date <br /> Remarks ......... .. ........... .Is... .. .. ... ..................,.... ... ..... ........ ................................. <br /> . : <br /> .. <br /> 0 <br /> v <br /> .............................................. ............................................................. ..... .................. : <br /> Inspection Date ....................................... .. ... .. <br /> Z.. .. . .....mK'rf ........ .. <br /> onin.. g Ad Istrator .... $ $ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faci ities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applic Won 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 ssued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or sl ecifications 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 />