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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as 'e w � •.�j <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m � <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> n A <br /> n <br /> v O <br /> .M��4.t.S......... !1.s. . ..........�. ....�e..a............... . .......................................................................................... <br /> OWNER (pleasepr ) CONTRACTOR or SURVEYOR or AGENT a <br /> �D of i <br /> a Y <br /> O a <br /> ADDRESS ADDRESS i'I /1 <br /> .......... �..' .e .........r:v.� 4............................................. ...... ..... <br /> .. ............................................................................... <br /> ADDRESS ADA <br /> DRESS O <br /> ........................................................................................... . . . . ................................................................................... i :S <br /> PH E PHONE ' <br /> .. . .. -E I] ... <br /> ... ............................................................... <br /> .............................................. 5,.. .�............................ :o <br /> PLU BER WELL DRILLER ;� \ : <br /> ........................................................................................... <br /> . ..................................................5 - <br /> ADDRESS ADDRESS ( <br /> .............. <br /> ........................................................................................... .......N-E.................................................................. <br /> PHONE PHONE LT,p Z :b <br /> DESCRIPTION `rcr 4. Sanitary Facilities: ° o ° EE <br /> 1. Work: 2. New Building Details No. Bathrooms .......... Ct:°Ey 'o <br /> iN� o <br /> New Building ,,,,,,,,,, Type of Construction: No. Bedrooms ••••••�••� <br /> m E <br /> Addition ....... <br /> x .... ..... ft. <br /> .,....,,.. .••„•.. ... .. Septic Tank Size Gals. ...... <br /> v Size ........... <br /> ................ ................ . ?�`..�;� <br /> Sanitary .., <br /> S <br /> Ize ... ..... <br /> i <br /> Filling/Grading Height........... 4a. Absorption Field Site: <br /> Stories ............... <br /> ...... <br /> Moving ...... <br /> .......... Area Soil Type .................................... iQ o <br /> ........... ................ .. <br /> Mobile Home Slope .......................................... -' <br /> .......... <br /> Privy ,......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... y i <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> ILA <br /> Subdivision .......... <br /> Seepage Trench .......... :r, <br /> ....................................I............... v <br /> Camping Unit .......... .................................................... Privy rte,�/ I <br /> Seepage Bed /F/"�:/ uJ <br /> ---- ------------------------------------------------------ c TIl <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched In Fig. A. Include road ?� <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway inter fl- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <G <br /> a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. d p' <br /> ______________________________________________________________________ tom. <br /> K, <br /> 5. Lot Size: Fig. A. 6. Location: : : :m <br /> ............................................................................... \7 :� <br /> ................ ft. x .............. ft. - ............................... sq.ft. J :A <br /> x. <br /> 0 <br /> I N � o. <br /> O � <br /> O <br /> O <br /> PC <br /> 0 W D <br /> W <br /> lee <br /> ` , <br /> 0. <br /> A c N < G N m N <br /> = m <br /> / Z o o n 70 <br /> � ry6 rPiew � o a nm 3 <br /> 5 1 <br /> r, m <br /> 9,.n�az-re <br /> ......:... ... .............. ......................................of Owner or Agent Date — <br /> X M <br /> Remarks ............................................................................................................................................................ m <br /> ............. T <br /> m <br /> ........................................................................................................................................................................................ o <br /> ................................ <br /> Inspection Date ....................................... .. �� U o a m <br /> ................. ........g............................................. Crirno <br /> Zoni Administrator 8 8 8 8 8 8 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on ull 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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />