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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < m <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code, and with all other applicable/Coouunty Ordinances and the laws and regulations of the State of Wisconsin. 3 a iLJ <br /> !{ .dH C 5Sz p t/Ya. E. ffY.��ri4e�. m O <br /> ......... . .......................................... . . ....... . .... . ................................. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a m <br /> . '. .�rt..f`S. !............................................... ............................................................................................ <br /> ADDRESS ADDRESS » <br /> MoL•. .e.., .�r........... .�.�.�..s'........ ............................................................................................ <br /> ADDRESS ADDRESS <br /> Ut <br /> ............ <br /> ........................................................................................... .PHON'H'0N-E.. .................................................................. <br /> PHONE N <br /> ."3°..9.-..75..7.-4,eX.R............................ ...........5. .c-.r........................................................... <br /> PLUMBER WELL DRILLER \ <br /> .......... <br /> .................................... ... <br /> . ................................................... .. ........ .................................................................... <br /> ADDRESS A..DDRESS.. o <br /> ........................................................................................... . ... ......................................... ....................................... o ,: <br /> PHONE PHONE.... .. z <br /> DESCRIPTION 4. SanitaryFacilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building .......... Type of Construction: No. Bedrooms .......... a I <br /> m <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... < <br /> Sanitary .......... Size .............. ft. x .............. ft. ......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................... ............... Soil Type .................................... r <br /> o <br /> Mobile Home .......... Slope .......................................... " 0 <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ..................................I <br /> Well y., home,garage, motel, etc.) Dry Well .......... Lv . <br /> Subdivision "\ Seepage Trench .......... F' I <br /> ......I... .................................................... <br /> Camping Unit .......... Privy {` <br /> .. Seepage Bed .......... <br /> y. <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched In Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTINGm <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O p a <br /> _____ <br /> 5. Lot Size Fig. A. 6. Location: <br /> .tq.r.. ft. x .,Z.k.L. ft. - ............................... s9. ft. .............................................................................., ,, <br /> :N <br /> ti y <br /> ) <br /> N ��� <br /> o \ <br /> :X <br /> f � s <br /> T C <br /> r .0 <br /> o i <br /> S <br /> wat Ib <br /> �y 7,7 fn r M m Z <br /> --'Xz�- maw � � <br /> - m <br /> Z Oo Dn 77 <br /> o <br /> m <br /> .................................. <br /> Signature of wner orAgent Date <br /> X <br /> T <br /> Remarks ......................................................................................................................................................................... m� � � <br /> m :69........................................................................................................................................................................................ - <br /> ........................................................................................................ .. ............................ ....... .......................✓........... <br /> n <br /> m <br /> Inspection Date ....................................... .�irrlJ.-n.. ..,7..,............. ..... tl ur u, o rn o r,r <br /> p <br /> Zoning <br /> Administrator t 8 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and site approvol granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage dlsposai systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or Install a septic tank, do any plumhing 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 />