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Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT µ :3 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as < v7 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a `� <br /> �?rjt..... A RR,��..�................................. ............... ............................................................................ o <br /> OWNER (please print) CONTRACTOR or'S OR or AGENT <br /> ........................................................ .......... ........ . ..... .. . ... . .... .............. ........ . <br /> ... . . ..... . <br /> ADDRESS ADDRESS �+ <br /> ...4( F.././..'.'..T 1.1..... .t. ...'... 8'7�... .ADDRESS............................................................................ <br /> r <br /> .... .... ... ......... ................................................................... ............................................................................................ ire <br /> PHONE PHONE :X <br /> .C41-0/N......f5�N-So ....................... <br /> .... .. .. ... ...................... <br /> PL ER WELL DRILLERS a t <br /> - :.. ......w.... t�57R... �s.f.SY ..g3.............. ............. ..... ...................................................... <br /> ADDRESS ' ADDRESS <br /> o <br /> ......7!s=... .6.-...Y6.ss................ .......... <br /> ............................................................................................ �,I o i <br /> PHONE .. . PHONE <br /> DESCRIPTION 4. Sanitary Facilities: P o o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building ....... .. Type of Construction: No. Bedrooms .......... <br /> 0 <br /> Addition ,,,,,, __.,,_ Septic Tank Size Gals. /. ... <br /> Sanitary ,,, ... Size ft. x ft. """"" �- <br /> Filling ........ Height............. Stories ............... 4a. Absorption Field Site <br /> Soil <br /> Moving .......... Area ........................... ............... Ll .. o <br /> Grading .......... Slope .......Z... 0....................... <br /> Mobile Home ......._- 3. Use (describe exactly, 1 -family Perc. Rate ......�f�.. ...................... <br /> Privy .......... ho e garage, motel, etc.y, Dry Well .......... r � <br /> Well /�, ,57.QK� Seepage Trench i... <br /> .......... ............... <br /> Privy / X '7....... <br /> Subdivision �JA /� /� may— <br /> _________________ ' � Y/QQ� ' } <br /> Seepage Bed � <br /> 73 .. . . ;N <br /> Location of proposed structures and existing structures, well,sewage systems, roads, etc_,should be sketched in Fig. A. Include road Q .� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I '� <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> a <br /> STRUCTURES AND PROPOSED STR UCTURLS AND ADDITIONS. o <br /> ----------------------------------------------------------- <br /> 5. LotFig. A. 6. Location: <br /> ..../ .. ft. xCL.L. ft. — ../..�.. .... sq. ft. ..................... <br /> to <br /> SGE /4T/190HED PUNS <br /> N O <br /> O J <br /> J <br /> 3 <br /> -R <br /> J <br /> Z <br /> O <br /> 7] <br /> N <br /> J <br /> m <br /> ]7 cnr V� Z <br /> C 0 d <br /> N AC7 D <br /> d d< : , <br /> Z 0 6 m N <br /> O J <br /> fA 3 <br /> ...... ..K.'...Y.......... .. /...�....� ...... \ <br /> O � <br /> ` m <br /> / d � � C <br /> Signature of Owner or Agent ate o C <br /> X 7J <br /> Remarks ......................................................................................................................................................................... <br /> o <br /> n ' <br /> ........................................................................................................................................................................................ � it <br /> :fn <br /> ...................................................................................................../s:}.......................... /./..../..................................... ? r _. (J1 N <br /> Inspection Date ....................................... - .2;�../ .. . . 7 lcYa�c,9?�:=:�,� <br /> ... . . . ..9. ........... ......... ..................... <br /> Zoning Administrator A J <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 inust be attacher) to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or stun 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 of specifications shall not be made without approval of the Zoning Adm inistratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />