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Es--� � i tt r7j-•� <br /> Burnett County Office of Zoning Administrator C 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 :3 <br /> _ o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as u, ;V <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m m EC <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a v <br /> _ � O <br /> . ear r. .:.... .wdl ................. ................. ....e...l.1.................. _ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CL <br /> ........ev!.1..? ....../[' .. ...................... dj <br /> ADDRESS ADDRESS <br /> ............ ob..er..fy..�it�. �..........`..- ...... . .......................................................................................... w 'f <br /> ADDRESS�. ADDRESS ............... <br /> ... ........ <br /> .....sf�r j.......................... . ................................................................. <br /> PHONPHONEO i iP <br /> ibf� <br /> ............. <br /> PLUMBER I WELL DRILLER i <br /> �p O <br /> ....... . . .............................................................................. .ADDRESS............................................................................ '\l m G) <br /> ADDRESS n p .A <br /> ........................................................................................... . .......................................................................................... O .P <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms ....QX.... C o <br /> New Building .... TYPOf ConstrItion: No. Bedrooms .... ..... 0 <br /> Addition .... •„•• ....•, ... 1�....... ,.,.,, Septic Tank Size Gals. ......(...0 :O <br /> Sanitary . ..) .... �,. ..... .�.1(... �\! <br /> Size ... 4 .. ft. x ... ft. �D <br /> FillinglGrading ...,...... Height............. Stories ............... 4a. Absorption Field Site: <br /> Z} Soil Type .................................... <br /> Moving .......... Area ..�..7..3.:... G. .-................. o <br /> Mobile Home <br /> Slope .......................................... <br /> .......... a <br /> Privy 3. Use (describe exact) �family Perc. Rate ................................... i <br /> Well <br /> .. ... home,garage, motel, Dry Well .......... try. <br /> Subdivision ,,,,,,,, Seepage Trench .......... _1 <br /> Camping Unit .......... .................................................... Privy .. v . <br /> Seepage Bed L..S'X.J'y ��.{ <br /> 00 <br /> Location of proposed structures and existing structures,well, sewage systems, roads etc., should be sketched in Fig A. Include road 91 Q RTsetback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter 27 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : o ; <br /> ----------------------------- -------------------------- <br /> 5. Lit Si7�: ,r4 Fig. A. 6. Location: <br /> .. .�......... ft. x .............. ft. . ................. sq. ft. ............................................................................... <br /> 1\ OD a j. <br /> 03 <br /> p" <br /> 19O, <br /> 0 <br /> a <br /> Rif <br /> o .� <br /> Awe d <br /> cll <br /> '•o <br /> �Qa � <br /> 6— U,A <br /> 0 O n� <br /> /O'D <br /> ure of Own gent ate <br /> X 70 <br /> Remarks ......................................................................................................................................................................... m m.� p <br /> m <br /> 6 <br /> .......................................................................................................././/..//.11.............. ..........`J./. ............................................. 1 H T <br /> Inspection Date ....................................... L.aflQrizo..�....(.. ............. o U-o m <br /> //// Zoning Admi strator�J $ $ $ $ $ $ 0 <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 be made without approval of the Zoning Administratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />