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Burnett County Office of Zoning Administral or fC 6g�g <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 r„j <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd Q # M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws i nd 3 <br /> it <br /> regulations of the State of Wisconsin. <br /> /71/Cha�1.... izecp.................................. ...... se/f................................................................. .... A <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> a�3... C✓C�.�N/4.G��.. ...................................................................................... ..... a ' <br /> ADDRESS ADDRESS <br /> lt�: v....mc/........�WQ../V....................... . . . . . ........................................................................... ..... - z <br /> ADD R SS ADDRESS <br /> 7P0. ....... ..lo....................................... ... .................................................................................. . <br /> .... Nla,(-��......... . <br /> PH..NE 14.C.Q. ....!S.'.N.. .SOI�.Y..I........ PHONE <br /> .. . .. .. ........ .. ...................................................................................... ..... <br /> PLUMBER WELL DRILLER <br /> .... <br /> ADDRESSk/ ADDRESS yT� <br /> N/J3 .. <br /> PCoG.-..7 (a......................................................... ...................................................................................... ..... o ° <br /> PHONE PHONE Z ,? r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms �— v <br /> New Building Type of Construction: <br /> No. Bedrooms <br /> .......... <br /> Addition ...... .. ...... Septic Tank Size Gals. <br /> Sanitary ,✓... Size'. ft, x ....3 : ft. .... ..... <br /> DO <br /> FIIIInglGrading .......... Height............. Stories ..... 4a. Absorption Field Site: <br /> Moving <br /> Soil Type .............................. ..... <br /> .......... ......................................... r <br /> Moblls Home Slope .......................... o <br /> .......... <br /> i <br /> Priv Perc. Rate ..............3. <br /> Privy .......... 3. Use )describe exactly, 1 -family .......... ..... <br /> Well .......... home garage,motel, tc.) y <br /> Dr Well .. ..... � <br /> Subdivision ,.,,,,,,,, / {/ Seepage Trench .... ..... z <br /> Camping Unit .......... ..... il . .. ... Privy .... ... . r i i <br /> Seepage Bed <br /> Cn <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 locate I at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. ;p�, „<—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :C� o .' <br /> ____________________________________________________________________ _ <br /> 5. Lot Size: Fig. A. 6. Location: C� <br /> ................ ft. x .............. ft. . ............................... sq.ft. ........................................................................ .... <br /> j 1- <br /> A to I ISE I�G� . DI <br /> N <br /> VV <br /> TUf�t� 7 �")�� Sf. <br /> 0 <br /> ��G�, I ��: �l1✓� �i rCh 0 <br /> oILI <br /> a � <br /> 6i � II nP <br /> 0 0 <br /> 0 00 rnvtnr DC fin <br /> am nag <br /> < ; d C y > ] 3 <br /> Z ON O > <br /> „ n ; y <br /> c o mO <br /> A <br /> ........................................................................... ...................................... <br /> . m <br /> Signature of Owner or Agent Date <br /> n <br /> m •• <br /> v <br /> ......................................................................................................... .................. ......... ....... oo <br /> y ....... .......... Q <br /> Inspection Date�.�.c ..-'. .{ �77 N o o m <br /> ............ ... ./L� .l......./ 7.7� . �.............. .. o 0 0 0 m <br /> Zoning Admi ' trator641 "� o S o 0 0 Sin <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faci ities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applic ition 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 ssued. 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 APPROVED. <br />