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Burnett County Office of Zoning Administrator 17 0 <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 'Z p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulat'ons of the S�-of Wisc nsin. 3. <br /> .V.o............1.!'s d.r................... m <br /> ......... ............................................................................................ <br /> OWNER (plass print) <br /> CONTRACTOR or SURVEYOR or AGENT � o <br /> R ....... ............:.....t,.t !7 l.. , / 'a In <br /> ADDRESS ..�.. .. ADDRESS............................................................................ 0 (� <br /> � i I <br /> . . ................................................................................ <br /> ADDRESS .AD.....D.....RES................................................................................ <br /> S �'• °� <br /> PHO................... ................................................................ .PHONE................................................................................ <br /> ..... <br /> ...........K.s............................................. <br /> PLUM ER WELL DRILLER <br /> ........................................................................................... .ADD.. .. R. .... ............................................................................ O <br /> ADDRESS ESS...... L) :O <br /> n d <br /> . . .................................................................... . . ........... .. <br /> .............................. ....................................... <br /> ». < <br /> PHONE PHONE....... ' <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> Q� o <br /> New Building ....... .. Type ofCons r/ oyt. No. Bedrooms ... -: <br /> Addition —C_ /f� Septic Tank Size Gals. <br /> Sanitary Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... m <br /> Mobile Home .......... Slope .......................................... v » <br /> o <br /> Privy .......... 3. Use (describe exactl '1 -family Perc. Rate ................................... m Ci <br /> Well Dr Well .......... <br /> . ........ home,garage, motel,etc. Y <br /> Subdivision .......... Seepage Trench z <br /> .................................................... ..... .... <br /> CampingUnit ........., .................................................... Privy _ <br /> Seepage / ppl/ h i :- <br /> Vj---------------------------------------------------------- ___________ y <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 located at 'lN :� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. (J1 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: :t <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... 1" t <br /> �qq 'fi <br /> n <br /> N ap <br /> O a = <br /> _ <br /> s :W <br /> ul <br /> ul %I <br /> a <br /> Je I <br /> IBX�9 <br /> c � 0W0CC <br /> n f^cr < = = o - - m <br /> m <br /> 0Z <br /> c a a 9 <br /> PZI <br /> '2 D <br /> .. ................ ........ ............. ... ....... ............ A <br /> Signature of er or Agent Date <br /> o : O <br /> - <br /> o . <br /> i <br /> . ;/./� ..... s1v - .................................................................................................................... <br /> Remarks ` m :... n <br /> o : $ <br /> .......................................................................................................... o <br /> Ins ctionDate ...-2 -1-7 �`"L� eJ ^' ' ' ^' m <br /> Pe ............................ N O O tit <br /> Zoning AdnaKistrator <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 application 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 />