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��—j•i C-C}7J� <br /> Burnett County Office of Zoning Administrator T 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N <br /> shown herein. The undersigned agrees that all work shall become in accordance with the requirements of the Burnett County Land Use mC r <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a l \ ]V <br /> \'� <br /> U �. <br /> . .........:.............Ai>z2sv .. ..5.... ... .......................... <br /> ...t% 5m ... . .............. . ................ N <br /> OWNER (please print) r CONTRACTOR or SURVEYOR or AGENT <br /> ^ o. <br /> Rfe..II:.........W.:...0 Late-.."l.. .......W.. :h..ti....1 fie..,.....( >,1-............................ d <br /> ADDR SS ADDRESS <br /> >Z.........6'9g.C,',.............. ............................................................................................ <br /> ADDRESS ADDRESS <br /> 71 ..... �.b......alb.z................................ ...............��.5.. .. `� . 33 3....................... .... <br /> o �f �r ,.yam <br /> PHONE s- PHONE C �.S.::I L.. .C. .........# .. .I..l. �.L.L 'N <br /> v ..... .P_i. . . , .ea.... . :� <br /> PLUMBER /. V Q WELL DRILLER <br /> 1...CIOL....... ....................... .........I............. ec?�rac ..,.....1 11-................. <br /> . ... <br /> ADDRESS ADDRESS ill m L7 <br /> 71..5.. ....... ...................... ................ 7.15. ...: 2:7....°.9`.1.53........... .............. <br /> PHONE PHONE z r <br /> DESCRIPTION 4. Sanitary Facilities: Z ° o ° <br /> No. Bathrooms ' <br /> 1. Work: 2. New Building Details <br /> New Building q No. Bedrooms <br /> ,,,, Type of Construgtion: "•.... <br /> V C'ID OtS E Septic Tank Size Gals. .......... � <br /> Addition ... ...... .....�...........................y..� < <br /> Sanitary ... .... Size ...z. ., ft. x """"" <br /> Filling/Grading .......... Height...�z-..Sx?.... Stories ... Z.r... 4a. Absorption Field Site: <br /> 1 3 Z, c l Soil Type .................................... w R <br /> r <br /> ..?............... <br /> ...... . . .).......!`}.�.. o o p <br /> Mobile Home . . Slope ........................... <br /> Moving .......... Area ........... ............... . � <br /> Perc. Rate ................................... .0 F <br /> Privy .......... 3. Use (describe exactly, 1 -family w y� <br /> Well .......... home garage, <br /> "' / ... motel, etc.) <br /> Dry Well .......... <br /> .......... .......... <br /> Subdivision Yy . SeeWtry <br /> T .B <br /> e Trench <br /> Privy <br /> Camping Unit .......... .................................................... .......... O <br /> -------- Seepage Bed------------ -C <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A- Include road C c <br /> setback, side and back yard dimension and location and setback from all bodies of water. It property Is located at a highway Inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ------- <br /> 5 of Size: Fig. A. 6. Location: 0 <br /> 7 <br /> Pirt <br /> kln4p (OCt/NSllif] <br /> ft. x .............. ft. — ......—..... s4. ft. ...--- S2L 3 S TA GN p w <br /> ........ ............11� .............................. P <br /> V4 313 POr bel <br /> 1 <br /> N � 0 <br /> O ;Ut = <br /> 1 w , ", K w o l <br /> -H <br /> Z 3 <br /> ?Iws� a jg wail - <br /> k <br /> ,I ib <br /> i� i o <br /> 1 � <br /> 70 N r 9 m m <br /> c: F <br /> `G Nam m m <br /> O m y n <br /> Z <br /> iso . <br /> {���• - x/.- . 3L m <br /> . . .............................. .......!./........... C>..)...... o [ C <br /> Signature of Owner or Agent Date <br /> X <br /> T m <br /> Remarks ......................................................................................................................................................................... .� <br /> v <br /> m <br /> ffl <br /> ........................................................................................................................................................................................ II : : <br /> /J <br /> arnrq� i m <br /> T <br /> Inspection Date ' I°' m <br /> ....................................... .. .......... .................................. o . o <br /> Zoning Ad Inistrator,('U g $ 8 g to <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 plumbing or Start any build- <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 lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />