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Burriett County Office of Zoning Administrator SG e <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 M n <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,e c :.(v <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin, <br /> 12 o <br /> n In <br /> OWNER (Plasse print) CONTRACTOR or SURVEYOR or AGENT ; <br /> .. '�t' ..T........�7.. .1�........................ ..... . . . . . a q <br /> . . . .. . . . ............................................................................ d � `:� � <br /> ADDtR�ESS ADDRESS � ^ <br /> .i......5.(....�. ��I.:.Y.. :W. ..................... <br /> ADD ............................................................................................ ,U' iT• <br /> E ADDRESSncj� t <br /> PHONE �. .. ..i.... .PHONE................................................................................ <br /> a ........f�2�.tf3-�.. ................. .................. ......................................................................... <br /> PLUMBER WELL DRILLER .O <br /> T�..flt �li4;? 1 ... ...( �1...'............. ............................................................................................ <br /> ADDRESS ADDRESS............................................................................. ° .o <br /> r............................... o <br /> PHONE PHONE ' <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms V <br /> 2. New Building Details ......•••• ` o <br /> New Building ,.-.)(,,.. Type of Construction: No. Bedrooms .......... ;� R <br /> Addition Septic Tank Size Gals. .......... `• <br /> Sanitary ...�(,... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... r <br /> .......... Area ........................... ............... <br /> MODIIs Home SIOc <br /> P¢ .......................................... v - <br /> .......... <br /> Privy 3. Use (describe exactly,'1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well <br /> — UJ <br /> e Trench o <br /> a <br /> pg <br /> Subdivision See """"" <br /> Camping Unit .......... ................................... ................ Privy .......... <br /> Seepage Bed .......... ,\✓ <br /> ______________________________________________________________________ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Vl ° <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at Q 9t" <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. \\ N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS_ __ ------- pv o <br /> ____________________________________________ <br /> 5. Lot Size: nn� Fig. A. 6. Location: <br /> P...... ft. x .�A.Q.4. ft. — .. .. .1.. .... /... 5q.ft. ..................Looe C(4Y�............................. <br /> . .......... <br /> Dax�yu �oc�L> L9a r2d, d�u <br /> des ,) o <br /> the i2o� -- �yhf - �- o ►c <br /> 4G &iIc4NA, o <br /> a <br /> I T <br /> �2o <br /> AJ 6DW <br /> 0 -Udd > mm -0 <br /> 0 Mrr < J O 0 - - M <br /> m �n•c -� am nay <br /> c i <br /> Z p N_ .G O m 10 <br /> c _ n : <br /> O 0 <br /> 6��F� ��JE � � <br /> ....... .......... ..................... .`.... .... ....... ...... . ..... ..... ............... m K O <br /> ignature of ner or Agent Date <br /> MAY DE REQUIRED <br /> ...<./✓ % <br /> l <br /> Remarks . ....'..f L <br /> v <br /> ............................................................................................................ .... ................. . ....................................... <br /> 1 -- y NgNo � Nm <br /> Inspection Date m <br /> Zoning inistrator 8 8 8 8 8 8 YA <br /> NOTE: A preliminary site inspection must be made an a 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 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 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 AND APPROVED. <br />