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Burnett County Office of Zoning Adminisi rator it 17 gg� <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements f the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the la and <br /> regula oft a act Wiscon in. 3 <br /> ..... �.. 1IZIN.l�.2................................. �e d — <br /> OWNERI print) .................................................................................. ........ e <br /> /LkI _ CONTRACTOR or SURVEYOR or AGENT — e <br /> I...... <br /> Box. . ......................... <br /> .................................................................. ......... <br /> ADDRES ADDRESS <br /> v k ! Gam �i : ... SYff ........... .................................................................................. .........ADDRESSADDRESS <br /> 715.... .53...,..,...3......c .......... .................................................................................. ......... <br /> PHONE PHONE <br /> ........................................................................................... WEL. . .L..DRILL..R'I'L ..ER .................... ............................... —...... ......... <br /> PLUMBER <br /> ADDRESS C <br /> ........................................................................................... PHONE........ ...... ...... .. <br /> PHONE ... . .............................................. ........ 0 .: <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathro <br /> 2. New Building Details • •••••••• <br /> New Building .. .. .... Type of ruction: No. Be oms . ........ ? ° <br /> Addition -.X.,., ...... •• �-�- Sep Tank Size Gals. . ........ <br /> �.................. y.......... . ........ <br /> Sanitary .......... Size .*1 ....... ft. x ....9....... ft. <br /> Filling/Grading .......... Height......[.]'A. :�ries ...�.......... 4a. Absorption Field Site: ' <br /> Moving .......... Area .. ............................ Soil Type ........................... ........ i <br /> .......... . r <br /> o <br /> MODIIe Home .......... SIoPe ................................. ........ .. <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .... <br /> w <br /> Well .......,,, homhe ,�Ca9 e,mgggte�l, tC.l Dry Well . ........ <br /> Subdivision ......,... .....V�J��'�'t�� 5/O f" Seepa rench . ........ o <br /> Camping Unit ....,...{Y�( .... . ... (/ ....... Priv <br /> .......... ar.................... S . ........ p <br /> --------------------------------------------------- <br /> ------------------------------------------------- -page Bed . ........ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc. should be sketched in Fig. A. rn <br /> c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at C, <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the lnterse ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------- <br /> 5. Lo S' ------ <br /> /1��� Fig. A. 6. Locations ' <br /> �/. �.. ft. x� .. ft. — `.a...OI.-�C�./<.!Y.s.... sq.ft. ..................................................................... . . <br /> . ..... <br /> _- _-_ Roo, . <br /> O <br /> o <br /> ` D row ~ <br /> J <br /> I <br /> N-� :)j <br /> >50D <br /> p <br /> d <br /> v� <br /> Q� D W GO 1— > m to y <br /> �UV m �a•c c: <br /> N "� asy <br /> 1� I� Z�0 O roto <br /> 2 — -11m <br /> On <br /> Li <br /> Signature of Owner or Agent mDate O <br /> o : <br /> o , <br /> T n <br /> Remarks a . <br /> m •• <br /> w. v <br /> o o <br /> ............................................................................................................ : c <br /> Inspection Date ....................................... .... ... a N o o $ m <br /> Zoni of inistrator $ $ $ ro y <br /> NOTE: A preliminary site inspection must be made and sit pproval 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 appli ation 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 beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />