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Burnett County Office of Zoning Administrator c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describednd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the :fit <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulationsof the Stateof Wisconsin. �7 a <br /> .W..I.. '.I.f.!?Y .........Lt..'..�.'..I.��.:e.n /Y.~..................... ..................................................................................... ...... A <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT ; <br /> A <br /> ............... d.4... ................................................. ..................................................................................... ...... d <br /> ADORE ADDRESS <br /> Euls..........Xet.........s^a 6/3 3 ! 9 a77 � l7 y X31 <br /> ................................................................. ...... <br /> ADDRESS ADDRESS — A <br /> ........................................................................................... ..................................................................................... ...... <br /> PH N PHONE <br /> i <br /> .. <br /> rofa . . ............................................................ . . . ....... .. . . .............................. .............................. .. ...... <br /> PLUMBE WELL DRILLER R <br /> O iA <br /> ........................................................................................... . .AD.. ................................................................................. ...... _. <br /> ADDRESS DRESS 'm C) <br /> n O nt <br /> ...... ...... <br /> ........................................................................................... .............................................................................. . <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° <br /> 1. Work: 2. New Building DetailsNo. Bathrooms • C) o `Y <br /> New Building Type of Construc�'on: No. Bedrooms ... ...... <br /> Addition ,•••• • ,,,,, r,i„,!i%�;�q„ , Septic Tank Size Gals. .. ....... <br /> .......... . . �-C_X.. . ......... . <br /> y .0..4. i <br /> Sanitary .,,h..... Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... i r- <br /> Mobile HomeSlope .................................. ....... <br /> ......... Perc. Rate ........................... . <br /> Privy 3. Use (describe exact) .1 -family H <br /> Well ,,..,,.,,, home,garage,motel,etc.) Dry Well m• •� Z <br /> Subdivision .......... Seepage Trench .. ....... o <br /> ............................... .................... 'A0Camping Unit Privy . . C\` : <br /> .......... .................................................... .YJ <br /> Seepage Bed � .. 6 ?h <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local ad 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. :-T ^l o Gj <br /> --------------------------------- ----------------------------- - o ' 'f+ <br /> 5. Lot Size: Fig. A. 6. Location: :L' t <br /> ................ ft. x .............. ft. . ............................... sq.ft. ....................................................................... ....... Q i i <br /> A <br /> ;p� n <br /> o � <br /> O <br /> o <br /> N <br /> Z ` <br /> ° (�v <br /> b <br /> N <br /> n�C4,C/ <br /> . D (n , S. m m <br /> fY1` A !Na > > S. m <br /> m_ N n - m EL <br /> c < m m > > ,= <br /> N x7 m <br /> Z$o m � D 1 <br /> u 14 n 9 <br /> o m <br /> a 0 : O <br /> R ��- y-� <br /> ° <br /> .................... <br /> Signature of r Agent Date 8 <br /> Remarks Q ” y <br /> .... ..... .................................................................................................................................. .... <br /> � .. <br /> � . <br /> ........................................................................................................ .. ....I.............. .. . .... ............. ... .. <br /> p <br /> _ . m <br /> Inspection Date //-..lG.-. �............ <br /> Zoning Administr forr, <br /> $ $ 8 S 8 8 N <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 appl cation 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 />