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Burnett CountyOffice of Zoning Administrator d 0 0 0 <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 located as <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 a <br /> a <br /> ........ a ��T ..................... H o <br /> . . . ...... . . . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT M <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> PHONE ^^ , PHONE :b <br /> ............... ... ....................................................................... ........................................... ................................................ <br /> PLUMBER hh^^ WELL DRILLER <br /> .T g .. �.U.....1 .. ............................................................................................ <br /> ADDRESS _ ADDRESS <br /> c o <br /> ................ .................. ................ . ... ........................................... 0.. .......... ct <br /> ..�. ......... ....... <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> v : <br /> 1. Work: 2. New Building Details No. Bathrooms ....+�,... i o <br /> New Building ........ Type of Construction: No. Bedrooms . .P..S,. `ISD a <br /> Addition •.•••,•,•• ...................... Septic Tank Size Gals. �. <br /> Sanitary <br /> ...j.S,.. Size .............. ft. x .............. ft. 4a. Absorption Field Site: <br /> Filling/Grading „ Height............. Stories .......4....... <br /> rzSoil Type ..............Moving Area 7 .�� 'o <br /> Mobile Home Slope ....................... :s' <br /> i <br /> ., <br /> t9 / Perc. Rate <br /> Privy 3. Use (describe exactly, 1 -famil •• • • • •....... 3. ...... �\ <br /> Well ,,.,,,,,,, home garage, motel, etc.) Dry Well .... <br /> Subdivision ........,. Seepage Trench .......... <br /> Camping Unit .......... ......0 .....•�,•_,.•,�.,/ Privy ..... <br /> ...... !t, ...... ...4.4... 44. <br /> Seepage Bed .... <br /> -------------------------------------------------- ------------------ (h <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road 'ic, <br /> T <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter O � a • <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING r .� is <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. a' <br /> --_— _________________________________________ <br /> 5. Lot Ize:r ( —LEc 367 Fig. A. 6. Location: <br /> �.... ft. x ..,ii... ft. — .TLr..t/........ s,!5.. 6fW4- .� <br /> . sq.ft. ................. .1L�.fr�L .... ............... <br /> LAytEs �QoF O o � P <br /> €U <br /> N Nj O <br /> o (\Vjl 0 <br /> O <br /> @t o <br /> 9 <br /> Z <br /> S <br /> o <br /> -D4A <br /> MasZ <br /> Q < c m <br /> 1 bib m : ` m <br /> o $ � : am <br /> . . m <br /> .............. . .. ........ ..... . ... .......... <br /> Signature of Owner o gen Date o C <br /> X 70 <br /> Remarks ......................................................................................................................................................................... m m <br /> EA ' <br /> ...................................................................................................... .... . ............................................. <br /> n <br /> r � o °� o � m <br /> .. ... .................... . <br /> Inspection Date ....................................... Q.?.?.2.1✓�.. ./.. . /C. ................ m <br /> ZoningAdmipTstrator <br /> 888888tH <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 he attached to <br /> this application before a permit will be issued. Do not 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 />