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C9-7"Cen ,nf <br /> Burnett County Office of Zoning Adminis rator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. W <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and loc ted as 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lad Use c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wim onsin. 3 a — <br /> a/.'oz...... :..F.e../eyV................................... ............................................. ... .... . .... ..... ......... <br /> OWNER Iplease print) CONTRACTOR or SURVEYOR or AGENT <br /> ....4�m ....�...h.i4iie.,....t/......................................... . ... . . . . . _ �. <br /> ADDRESS DRES ............................................................................ Q, <br /> ADDRESS <br /> �4 DO <br /> MAI.... <br /> ss t3............................. . .......................................................................................... <br /> ADDR SS ADDRESS <br /> �al.��...... .7.. ................................................. <br /> PHONEPHONE - pip <br /> ......k/ads.....,ahh4/m...................................... <br /> :............................................................................................ GQ <br /> m <br /> WELL DRILLER <br /> PLUMBER {V <br /> , x.....� .. L, wall <br /> /��.�,... ........ 3................................................................................... _ q <br /> ADDRESS ...... .......k. .... ... . . ADDRESS ......... <br /> o <br /> .....dela.-..7�?..C�............................................ ............................................................................................ c <br /> PHONE PHONE N :. <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms ... <br /> 2. New Building Details ••• � ' <br /> New Building 7 Sep Bedrooms <br /> ype of Construction: ���� •••• <br /> Addition .....,,... Septic Tank Size Gals. 7.T�. <br /> ... ................................................ . . !�.< <br /> Sanitary ...✓.... Size .............. ft. x ......4....... ft. ........ . 'y 1 <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area .. Soil Type ............... .......... ......... i <br /> r <br /> 0 <br /> Mobile Home Slope .................... ., <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate .......... :. ,n?.!.. ........, �. <br /> Well ,,,,,,,,,, home,garage, motel, etc.) Dry Well ......... ,� p <br /> Subdivision Seepage Trench ......... i <br /> .................................................... <br /> Camping Unit Privy ....... . `,` <br /> .................................................... Seepage Bed .✓.. .7-' <br /> ------------------------------------ ------ --- co <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include. road C `R` <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwa iinter ( a <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXI 3TING C> ' 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> .________________________ ------------------------------------------- --- <br /> V" a <br /> 3 <br /> 5. Lot Size: Fig. A. 6. Location: r� <br /> ................ ft. x .............. ft. . ............................... sq. ft. .................................................................... ........., <br /> n <br /> N p <br /> o � <br /> o <br /> 0 <br /> �a <br /> T <br /> m to Z <br /> n cr <br /> _ F <br /> on C <br /> m <br /> D <br /> �ost� nro' <br /> .,�.. .............. ... ..... ..... ........ ...........9/ /��. ... <br /> 0 <br /> algnature of Oyvn qr Agent Date �.+ <br /> U�/'� - i : X : 37 <br /> Remarks ...... ..... '.... 'G ...:./. ''................................................................................................................ r m <br /> p v <br /> ......................................................................................................... .................... ... <br /> G� ..... <br /> -7 ............. ...... <br /> Inspection Date ../.....�.'� X1.7...... ... P..... ... ..... G UU o o $ m <br /> ............................ . ... .. � j . <br /> m <br /> Zoning Admini rotor � t7'1 Q$ $ $ $ $ V� <br /> C <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a Septic tank, do any oh-liabinof or start any budd- <br /> ing until a permit has been Issued. A permit may be revoked if misrepresentation of any of the Information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of tl e Zoning Adm inistratol- <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ND APPROVED. <br />