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Burnett County Office of Zoning Administr itor V 7 i <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 describe and '2 # 0 <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 <br /> regulations of the State of Wisconsin. ��L/ �_ <br /> f M <br /> / n <br /> OWNER Ipl print) CONTRACTOR or SURVEYOR or AGENT <br /> . .± X12 .�t1 J ....9jgq�a <br /> ...... .................................................................................... . ..... o. y-: ^ <br /> ADDRESS ADDRESS �R \ <br /> . . . ................................................................................ .A...... . .RESS....................................................................... ....... <br /> ADDRESS DD <br /> PHONE................................................................................ .PHONE........................................................................ ....... I :� <br /> 1 <br /> PLUMBER WELL DRILLER � <br /> A...D..D...R..E..S.S.. ............................................................................. <br /> ADDRESS . •0.............. ............................................................ . <br /> n o <br /> PHONEPHONE Z N � hl <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms ` v <br /> 2. New Building Details i c :O <br /> New Building .......... T_ pe of Construction: No. Bedrooms .. .. .... <br /> Addition A - FEZ 4 R <br /> E �R�craC Septic Tank Size Gals. pd <br /> .......... K....................Y....,..... . <br /> Sanitary .. ....... <br /> r .......... Size <br /> y '3 c............... ft. x ... <br /> Filling/Grading .......... Height............. Stories .S?..:'f!= 4a. Absorption Field Site: <br /> .... E <br /> Moving Area L.a. .m...S,S..F. / Soil Type ............................ ....... <br /> ` o <br /> Mobile Home .......... Slope ..................... ............ ....... : N <br /> ............ ....... m <br /> Privy .......... 3. Use (describe exactly, 1 •family Perc. Rate ............... o ; <br /> Well ,,,,,,,,,, home,garage,motel, etc.) Dry Well .. ....... M , <br /> Subdivision Z,�yf� Seepage Trench .. ....... o <br /> Camping Unit Privy <br /> .......... ..... .'............ <br /> Seepage Bed '� kAi <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. n" `< <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca d at 11 1! <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. < <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.----------------------------------------------------------------- <br /> (( <br /> 5., of e: �� Fig. A. 6. Location: ' <br /> ..... f4r.(aA,fLt,/.l_.f .. ................. ...... sq. ft. <br /> o... ................. ..... . <br /> 3 c��fca <br /> r-4 <br /> O <br /> 15m a Ir [ <br /> T <br /> 0 <br /> a <br /> 11 M Co = Ch r- Dmto - <br /> l m Nam <br /> a O<, ; d C y > > <br /> Z ef <br /> O N O p m <br /> EL <br /> M0 C <br /> rr <br /> ' C <br /> .. ........................... . ....................................... ...../CL.... ... <br /> S" nature of Owner or Agent Date c <br /> T : N <br /> m •• <br /> a <br /> o : o <br /> o . c <br /> ..... . ..................... . .... .. <br /> Inspection Date .... ,,,,, , , �.� .J •••.., .... N 0 o <br /> Zoning Administr or <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <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 will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has beer 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 />