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&-"C'01� <br /> Burnett County Office of Zoning Administr for Ln <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 :Uy <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and '2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 a :( � <br /> regulations of the Slate of Wisconsin. /- ^ <br /> .1:..G'.71....... f�. Jn./ .C�.7. ............................. ................................................................ ....... � n <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> S .A.r..../ f.....Y......1�.X...}...�. ................ ....... I�— <br /> ADDRESS <br /> / 1 / ADDRESS <br /> .LI.CA.fi.../G.t.1.:.��.....r..W.S.......-'t...7..N.:J.�)...................... ................................................................................I.. ........ <br /> ADDRESS ADDRESS <br /> I�S..F........21..I/. ..................................................... ................................. <br /> PHONEPHONE <br /> . ............................................................................... <br /> PLUMBER WELL DRILLER (�\ <br /> O <br /> ........................................................................................... . ..... ........................................................................ ........ _. <br /> ADDRESS AD.. DR...ESS <br /> n no o i <br /> ° :S <br /> ...................................................Y.............................. ........ .: <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitar Faciliti s: ° o ° .f <br /> 1. Work: No. Bathroo <br /> �/ 2. New Building Details c <br /> New Building ,/,�,.... Type o{yJ / stru YJAn: No. Be oms . ........ R <br /> Addition . ........ ...........' .'.'.,5 ...f'/'CC:�!.er......... Septic ank Size Gals. . ........ <br /> .. . . . .. <br /> Sanitary .......... Size ..!a...... ft. x �.P...... ft. . ........ i <br /> Filling/Grading .,,,,,,,,, Height Jjb.:...... StBnes ......1........ 4a. Absorption Field Site: <br /> Moving .......... Area .......,�.`lQ........ Soil Type ........................... ........ ' m <br /> .................. SIOPe ...... ° <br /> MODIIe Home ...... ................... ........ <br /> Privy ,,........ 3. Use (describe exactly,'1 •family Perc. Rate ......................... ........ <br /> Dry <br /> Well ,,........ home,garage,motel, etc.) ..... `D <br /> Subdivision s�scu o .N 5"Ja' Se age Trench . ........ o .a <br /> .......... ..�.... .........0............. <br /> Camping Unit .......... /�'� .�j�c...� Privy . ........ np``\\ <br /> ....... ............................................ W ' <br /> Seepage Bed . ....- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F g. A. p _ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca led at Y \ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse tion. „<-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ------------------------------------------------------------------ --- <br /> 5. Lot ��: �� Fig. A. 6. Location: : 1 <br /> .. ....../..... ft. x .............. ft. - ............................... sq.ft. ..................................................................... ......... <br /> 0 p' <br /> O J <br /> J <br /> t7 <br /> 0 <br /> O <br /> N <br /> Z <br /> O <br /> W " <br /> Q J <br /> n A <br /> EL <br /> a tnvtnr Dmm1 <br /> JIm <br /> m Pn� J' Jnm nny <br /> D o y � m ,, mJ �°' 3 <br /> o <br /> La: y <br /> o c ' m <br /> : ; : o <br /> -- F7x m <br /> Signature of Owner or Agent Date <br /> in <br /> Remarks " y <br /> v <br /> .................................................................. ..:::.. ....... ................... ��9....................... ... <br /> ................................. DUO) .�/��,r�� N TI <br /> Inspection Date DUO) / \c�c//�.t.. e, v, v, v, o o u, m <br /> Zoning Administrato o g g 880 <br /> NOTE: A preliminary site inspection must be made and site a proval granted on all structures involving sanitary facilities before constr ction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans o 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 A PROVED. <br />