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Burnett County Office of Zoning Administrator �' o <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 of 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. M a <br /> ..R.I.Lk of l.............Pu...11C.. �g...r.................... . ................ .................................................... <br /> A <br /> OWNER (pleas <br /> e print) CONTRACTOR or SURVEYOR or AGENT s <br /> �P..E?... .y...... �..3..y........................................... . . . . ................................................................................... <br /> ADDRESS ADDRESS w <br /> ..s. !.x5r..c?....... ..4....... ..�.S..y. ................... ............................................................................................ vyly c+ <br /> ADDRESS ADDRESS <br /> i <br /> i 1 <br /> 3/�-• ss y � 8l vs A <br /> PHONE ...................................................... PHONE <br /> .. .. . Lt . ...... . .. . ....................................................................... <br /> PMBERBER t WELL DRILLER •� <br /> ........................................................................................... ..A.DD......R...ES................................................................................ <br /> ADDRESS S c <br /> i <br /> PHONE . . .................................................................... .PHONE................................................................................ � o <br /> Z r ;� <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° it <br /> 1. Work: 2. New Building Details No. Bathrooms .......... i <br /> —r 1 <br /> New Building Type ofC�nstruction. No. Bedrooms <br /> Cn .......... <br /> Addition ..�('.... ............k:...Q, Aa�1 Septic Tank Size Gals. .......... <br /> Sanitary �.........�..... x.s.A. E—J <br /> y ... Size .,.1.19..... ft. x ......(a...... ft. i <br /> Filling/Grading ••....••.. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... Ey r <br /> ........................................... <br /> Mobile HomeSlope .......................................... ° l <br /> .......... :tA <br /> Privy .......... 3. Use (describe exactly 1 •famil Perc. Rate ................................. . m <br /> 0 <br /> Well .......... home,garage,motel, etc. Dry Well ........., m ' <br /> Subdivision <br /> Seepage Trench .......... <br /> Z <br /> .......... <br /> Camping Unit ,,,,,,,,,, .................................................... <br /> Privy <br /> l..................................... <br /> Seepage Bed .......---------------------------------------------------------------------- <br /> � <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. _ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at c g y <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 5. <br /> , <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> -------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ..I.�SO TPpr sq.ft. ............................................................................... L <br /> Y i <br /> r <br /> N <br /> o np <br /> 0 <br /> N <br /> 70: _V <br /> m <br /> a n <br /> C 'm a a y <br /> s n8N p m 0 <br /> Z wo •2 D - i <br /> v N n <br /> 8 n m <br /> � o mO <br /> Sk........ .. ...........--- .............7— 'U - ~ J <br /> A v <br /> Signature of ner or Agent Date 8 <br /> Remarks <br /> m .. <br /> O : O <br /> ................................................................................................................................................................................. VhYI O <br /> •N m N m <br /> to T <br /> N + <br /> ction Date ....................................... ...................... to u, rn o o rn m <br /> ........................................................ .. <br /> Zoning Administrator 8 889 8 8 to <br /> ITE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> 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 /> tsued. 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 /> 'ed if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />