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✓ rI <br /> Burnett County Office of Zoning Administrator Q0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. _ c <br /> TO THE ZONING ADMINISTRATOR. The undersigned herbby makes application for a Permit for the work described and located as < PO <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> Everett Olson ............. �l <br /> (j�, o <br /> .... . .............................................................. <br /> R RO <br /> OWNER (please print).. CONTRACTOor SU VEVR or AGENT a ; <br /> 3.Zl..t§....7, th ............ . a <br /> ................... <br /> ADDRESS ADDRESS rn <br /> ............................................... . ................................................................................... <br /> . ....... <br /> ADDRESS ADDRESS <br /> ............. <br /> ........................................................................................... ............................................................................... <br /> PHONE PHONE <br /> A.anald...Di els...................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER i <br /> . ...... . . ............................................................................... <br /> &ox.W.......Sixea,..I>I.....Sl�17.2............................... 4 <br /> ADDRESS ADDRESS G <br /> n o <br /> m <br /> ....463,..2333.......349.,5364.......................................... ............................................................................................ o <br /> PHONE PHONE Z „_, r. <br /> DESCRIPTION 4. Sanitary Facilities: �49p� o ° <br /> 1. Work: F\ v <br /> 2. New Building Details No. Bathrooms ..1 0 !�Y o i <br /> New Building .......... Type of Construction: No. Bedrooms ..x.50. <br /> Tank Size Gals. ..........tic •fit <br /> Addition .......... .................................................... Septic <br /> Sanitary ..X...... Size .............. ft. x .............. ft. .......... <br /> Field Site: <br /> Fi <br /> i <br /> Absorpton e: <br /> e <br /> Filling .......... Height............. Stories ............... 4a. F � <br /> Moving .......... Area Soil Type .................................... o <br /> Grading .......... Slope .......................................... M <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Pere. Rate ...........3.....3.....3........ p� <br /> Dry Well <br /> Privy .......... home,garage, motel, etc.) <br /> Well Seepage Trench .......... � j�; <br /> ..x..... Privy <br /> """"" <br /> Subdivision <br /> .......... <br /> ....................................... .......... Seepage Bedjj <br /> .... <br /> --- :� 1€ <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- E- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING X. H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. . n' o <br /> r <br /> ----------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. <br /> �\ <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> r� m <br /> o <br /> 3 <br /> v a <br /> J <br /> O <br /> J <br /> b <br /> N <br /> N r- 07,00 <br /> m <br /> un m <br /> Z 0 0 <br /> O .-._ <br /> ee <br /> J N <br /> o <br /> `C o i : i m <br /> oZ�/vGY ....................... .....47� .:�� = s c <br /> 0 <br /> Signature of Owner or Agent Date m X m <br /> Remarks ............................................................................................................................................................................ <br /> o: <br /> of <br /> ......................................................................................................................................................................................... T <br /> InspectionDate ....................................... ."...'..r .:... ''T•`"_•°•'r?: .................................... 0 0 0 o M <br /> Zoning Administrator <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 must be attached to <br /> this application before a permit will he issued. Do riot 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />