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Burnett Cpunty Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT � 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <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 ind 3 <br /> regulatLLqnsof the State ofisconsin. » a <br /> obec ....b.r.:6isQ.f............................ ......�..i.K.9......leo.r. I ................................ ...... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> I.I.Q...SA.. an .....�.� a <br /> d <br /> ADD SS )[ ,•.� AD\DSS p� <br /> .M. .i... .....•�Y..7.3 i.................... ........Y..S f....Y✓ ....F� Val d <br /> ADDRESS <br /> ........................................................................................... ..................................................................................... ...... . <br /> PHONE PHONE � <br /> .. . ...... ............................................................................... . . . ....................... <br /> ............. <br /> ............................ <br /> ........... <br /> ... ...... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESSo <br /> 0 •((� <br /> .......................................... ...... 0 c 1 <br /> ................. <br /> .......................................... .. <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: 0 0 0 /� <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details " """' 'o <br /> 9 <br /> Now Building Type of Construction: No. Bedrooms .. ....... E <br /> Septic Tank Size Gals. .. ....... .. i <br /> Sanitary .......... Size .............. ft. x .............. ft. .. ....... <br /> Fitting/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: E <br /> Moving .......... Area ........................................... Soil Type ............................ ....... r <br /> o <br /> Mobile Home .......... Slope .................................. ....... <br /> Privy .......... 3. Use (describe exact ly,'I -family Perc. Rate ........................... ....... <br /> ° <br /> " """' T <br /> Dry Well <br /> Well home,garage, motel, etc.) — <br /> subdivisionSeepage Trench o <br /> .. ..... .................................................... Privy .... i <br /> Camping unit Seepage Bed .. ....... <br /> _______ __ _________ _________ _ tCA <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi 1. A. Q'Y <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota d at :i <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> 4—: <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — <br /> ------------------------------------------------------------------- — <br /> 5. Lot Size: Fig. A. 6. Location: — <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...................................................................... ........ <br /> i <br /> l Ly..YN � 0.®-'1 rl o <br /> ✓T7 t��t-r I J J <br /> Volt/ <br /> I � o <br /> Pa f <br /> ° <br /> T <br /> Z <br /> O <br /> p <br /> N <br /> J <br /> A <br /> 0MWr- Dco W -0 <br /> m � -Z <br /> O < ' d 0 o J J <br /> ° N J ntQ <br /> rn a <br /> p.. J <br /> � C <br /> x n : m <br /> Si.gn..a.t.u.r.e. .of...O...w.n.e..r. o.r.A"'g'e"n.t............................... ................D'a"t'e................ > O <br /> : $ <br /> T : u <br /> Remarks n <br /> u, <br /> o <br /> ................................................................................................I........... ............... . . ...................... <br /> o <br /> N m N N M <br /> Inspection Date ....................................... .. . ur v, u, o o 0 m <br /> TcLut..rd ....... ..... <br /> Zoning Administ a r . 171 0 <br /> o0gogggy <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 app ication 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 bee 9 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 ANDA PROVED. <br />