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Burnett County Office of Zoning Administrator - <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � }� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the t <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 `d <br /> regulationsof the Stateof Wisconsin. n <br /> ✓AMEN C, !dA ��3AkA J. i>tr�es�.N.... ...✓..C.M....�'. . c' !:rK... «!�7 �i C7i?...N... ....... A <br /> ......................... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT `n <br /> kl c.rL.....J ..tt3f.X.. E� �� . ..7. t= irN <br /> ...... ...................... .......................... ....... 'a <br /> ADDRESS .......................................... ADDRESS <br /> 4N i. .x,..�✓�:sceNs�.N.... .-45 ........ sN�L LAZE-�� wisc�NsiN........ ....... <br /> ADDRESS ADDRESS <br /> i i 00 i J <br /> ........................................................................................... . .................................................................................. ....... <br /> PHONE PHONE <br /> .......... ................... . . ............................................................................. ....... <br /> ......... ................... <br /> PLUMBER WELL DRILLER <br /> . . . ................................................................................ . .... . ... ................................................................... ........ m <br /> ADDRESS ADD..R..ESS.. 0 < <br /> •..•....................................................................................... . ......... ....................................................................... ........ <br /> PHONE PHONE. o o L <br /> DESCRIPTION 4. Sanitary Facilities: C <br /> y ; <br /> 1. Work: 2. New Building Details No. Bathrooms ••••• 0 C <br /> New BuildingNo. Bedrooms . ........ <br /> ,,,,x„ Type of Construction: !.0 <br /> r CLL Septic Tink <br /> Size als. . ........ <br /> Addition .......... ....... .......... ............................... <br /> Sanitary .......... Size ... IE . ........ <br /> .... ft. x ...¢�.... ft. `\. <br /> Filling/Grading 4a. Absorptio Fi d Site: <br /> .......... Height... ...... Stories ............... <br /> Moving Area ....1r45......................... Soil Type .... i ro <br /> MODIIa Home Slope .......... .. .................. ...... . <br /> """"" Perc. Rate .. . °i <br /> Privy ...... <br /> 3. Use (describe -family � � <br /> .......... Dry Well <br /> Well home,garage, motel, etc.) Z <br /> """"" f Seepage Tr nch o <br /> Subdivision ^/; � 'K� """"' ' <br /> .......... .�..�:...�:.....................f....-.... Privy ...... icad <br /> Camping Unit <br /> Seepage Bed .....— rn <br /> 9J <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in g. A. L ` <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property isloc ted at � _<g. <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. -� <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> (77 <br /> __________________________________________________________________ ___ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. ..................hDU1P.(...1.1L77.)...!-�:I.`�....... .......... <br /> IN � <br /> 0 _ <br /> N � � <br /> 0 <br /> o <br /> - I a <br /> Z <br /> w <br /> .iv <br /> rkcrnLit-n <br /> xu ocs - r) <br /> in (n 1- Dtp W <br /> m Na•c nm as 9 <br /> 8H O <br /> rn <br /> _.__ ._._ <br /> / - <br /> // T i <br /> Signature of OwAey or Agent Date o <br /> N <br /> Remarks <br /> N N <br /> ............................................................................................................................................................................... ........ <br /> . . .... . ............. <br /> ....................................................................................................... .. . . .. . . . <br /> O <br /> Inspection Date <br /> Zonin Administr for �'rl 8 g 8 8 $ <br /> NOTE: A preliminary site inspection must be made and site app val 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 at plication 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 b en issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans r specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />