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Burnett County_ Office of Zoning Administrator W 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as < <br /> wr <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 County Ordinances and the laws and regulations of the State of Wisconsin_ c <br /> RR 9 <br /> . .Y 5. = z <br /> ..... .... .... <br /> 1 .... <br /> OWNER bop ease print) ,,ff, / CONTRACTOR or SURVEYOR or AGENT a i� <br /> ... .f./..... OR/,-R.r..?..9.. .....40................ ..: .ADDRESS ...................................................................... <br /> ADDRESS /�(/ <br /> n <br /> ................................................................................... .... . .................................................... <br /> ........ . ............... ................... <br /> ADDRESS ADDRESS QfQ <br /> Vt :� <br /> ................................................................................ . . ................................................................ <br /> PHOPHONE ................�� i� <br /> �...-.5� 9._ -. ..e..9 .................. ............................................................................................ — <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS <br /> 0 < <br /> PHONE PHONE Z r :� <br /> ° <br /> 0 0 ^ <br /> DESCRIPTION 4. Sanitary Facilities: ^`1', <br /> 1. Work: .New Building Details No. Bathrooms .......... j„ o <br /> New Building .......... Type Of Construction: <br /> No. Bedrooms 0' ,r <br /> Septic Tank Size Gals. .......... ,� <br /> Addition ..... .... ....... ............................................ `� <br /> Sanitary Size it. x ft. ..... <br /> 4a. Absorption Field Site: <br /> FillinglGrading .x..... Height............. Stories ............... h <br /> Moving Area .......................................... Soil Type ..................... � or.- <br /> ............ <br /> MobileHome Slope .......................................... <br /> Perc. Rate ................................... i <br /> Privy ,,,,,,,,,, 3. Use (describe exactly, 1 -family O <br /> Well <br /> Y <br /> home,garage, motel, etc.) Se Well ....... <br /> """"" Seepage Trench .......... =� :� <br /> Subdivision .......... .................................................... Privy .......... <br /> CampingUnit .......... .................................................. <br /> Seepage Bed .......... <br /> _______________ yr an <br /> Location of proposed structures and existing structures, well, sewage systems, roads,ele.,should be sketched in His A. Include road t i <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property is located at a highway inter- <br /> �a <br /> ' <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> o <br /> 5. Lot Size: Fig. A. 6. Location :fRI <br /> d ' <br /> `�..... ft. x .............. ft. — ............. . ............. sq. ft. <br /> o <br /> So ' N�Avy B+2usfd <br /> a 11 <br /> o xI <br /> �kovn-PA <br /> � wM <br /> m `T <br /> _ 0 <br /> —_ O <br /> J Meed <br /> W�utT�btN��o� F <br /> °- C w' m r <br /> n oN. � � m ar <br /> Z caon 7 <br /> ...g. <br /> Signatureof Owner or....Agent ate.. ent... ............ ............. .............. .D. a"te............... <br /> X <br /> T C <br /> Remarks ......................................................................................................................................................................... � I <br /> ........................................... ........�nqAdministrator <br /> ......................... <br /> .................................................................. N I <br /> Inspection Date ....................................... . ... .... . ... ...P c $ c c <br /> NOTE: A preliminary site inspection must be made and site approvol granted on all structures involving rani a y facllitios <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must he attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing 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 Administiatoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />