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t / V'6w-/ <br /> Burnett County Office of Zoning Administr, for �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> g <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and r=te <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County ordinances and the laws and 3 i/, '?-�• <br /> regulations of the State of Wisconsin. a �•i. <br /> .`�U .....�f.�4.y..L> ..................................................... . ..................5..e�.rr ............................................ ....... - n <br /> OW ER (please pripnt) CONTRACTOR or SURVEYOR or AGENT <br /> .......................... .... .................................................................................... ....... 0 <br /> ADDRESS ADDRESS .01. <br /> w :rE ..,....wl.. .... .: .. ' ............... A _ <br /> .. .................................................................................... ....... is 1 il�J <br /> ADDRESS � •�� : <br /> ........................................................................................... <br /> PHONE . .... ....................... ....... ................................................ <br /> PHONE....... � <br /> ........................................................................................... <br /> PLUMBER . .................................................................................. ....... <br /> WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .................................................................................. ....... 0 <br /> ADDRESS G'1 <br /> n p <br /> . . . ................................................................................... � <br /> PHONEPHONE........................................................................ ....... 0 <br /> DESCRIPTION 4. Sanitary Facilities: ° o .°r. <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building ,,,, .. 7 No. Bedro ms ` 0 <br /> ••ype of Construcyon: � •• ••••••• <br /> Addition ,,,j4,,, , , „ ,�-Y(•M� Septic T nk Size Gals. .. ....... <br /> Sanitary .......... Size .. �' ..... .. ....... <br /> ...� ft. x ...J3..�..... ft. <br /> Filling/Grading .......... Height............. Stories .... .......... 4a. Absorption Field Site: <br /> Moving Soil Type .................. <br /> .......... ........................................... .......... ........ ` r <br /> Mobile Home Slope ........................... ...... ...... C <br /> ........ . <br /> i <br /> Privy Perc. Rate .................. m <br /> 3. Use (describe exactly, 1 -family •.-•••••. •... • <br /> Well .......... home,garage,motel, etc.) Dry Well .. ....... <br /> Subdivision �pnc� �,(7o,^�Spu fihy Seepage Trench 0 <br /> O .. ....... o <br /> -------------------------------------------------------------- <br /> L <br /> —Cemping Unit .......... .................................................... Privy ..... <br /> ------------------------------------------------ Seepage Bed— .. ...... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> __ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> . 7•c.�... ft. x ............. ft. — ............................... sq.ft. <br /> o <br /> b <br /> �\ <br /> p�'AUJjtE � � a <br /> deo <br /> D <br /> Z <br /> ypDitio/� „ <br /> F�Ly , <br /> X (n -arn r D m m -0 <br /> O wii < > > n C. m <br /> Iy m Na�c — nm aa � <br /> a5;,<. d C N J 3 <br /> Z <br /> ON On m <br /> // o . <br /> m <br /> / �a <br /> Si c <br /> �?L�. ... ... ................................ ....: ///// ./.j��7... n m <br /> SigrSature of Owner or Agent gaffe rV A : p <br /> ' o ; <br /> Remarks ................................. ...............P1. ... �.......... . (.......P�t�to ................. . ... ........ ............................ .... .. _ n <br /> NO <br /> So - o1gos- <br /> .. ....... ................ <br /> o <br /> .. <br /> $ : <br /> N O N rr <br /> ....... .. .................................. ... <br /> InspectionDate ....................................... .. . .............. ................... .. u, v, u, o m <br /> Zoning dministrator $ $ g g g y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary Fac lities before cc nstructio <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation before a permit wil <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 ors ecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />