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Burnett County - Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3 <br /> _ o :YJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as u, :t1 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> .�.�. ..........:Wl .y... .r................................. .. .-.... ...... s ... ................................... <br /> CI <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT M <br /> R .......1........... /..+................... ......ry................... ................................... d <br /> ADDRESS <br /> �.L' ......L..........W.5............................ ...... . .,"�,(r Fq�......................................... °Q <br /> ADDRESS ADDRESS �l :C <br /> ........................................................................................... . ........................................................................I................. <br /> PHON PHONE <br /> ..... ...e. :.......�o-e. p. r.................................... ....C�..�c . .. .........[?. .C..► .�.............................. p� <br /> PLUMBER WELL DRILLER iJ i <br /> W. ..r. o <br /> ADDRADDRESS <br /> Q "�� no <br /> r <br /> a. 1... a......Fs'.................................... oe <br /> PHONE PHONE Z H r � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details """ <br /> New Building No. Bedrooms ` o <br /> ,. Type of Construction: <br /> Addition ... ... .,�!(�.w��Q.r.................... **tic Tank Size Gals. ..... . .. <br /> Sanitary <br /> .�5..... Size .............. ft. x .............. ft. }-�d��+^—� <br /> FillinglGrading ,..,...... Height............. Stories ............... 4a. Absorption Fl�ld Site: <br /> .. . r <br /> Moving .......... Area .................................. Soil Type ...................... .... ....... <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use describe exac 1 -family Pere. Rate ................................... <br /> Well C..... orae aro e, motel, etc. Dry Well .......... (� <br /> Subdivision Seepage Trench .......... i <br /> 9 9 <br /> .......... .................................................... Privy .......... <br /> CampingUnit .......... .................................................... <br /> Seepage Bed .......... C, Z : <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road .ch <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 /> 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. "` o <br /> 5. Lot Size: Fig. A. 6. Location: _ <br /> t <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... g <br /> P <br /> FSS <br /> 0 <br /> N O' <br /> o n <br /> 0 <br /> z <br /> X o <br /> a � <br /> v m <br /> c r M N m m <br /> b a a m g F <br /> xa on m to- <br /> a U G N p <br /> m <br /> Z � � <br /> n �o <br /> Cai <br /> ti <br /> p <br /> .-.� <br /> Signature of Owner or Agent Date s <br /> — <br /> Remarks ......................................................................................................................................................................... <br /> T : m <br /> m <br /> .................................... ................. <br /> . ........... ....................... °... ..................... .. .................... l <br /> 7 �- �5 ° ' " m � Nm <br /> Inspection Date ....................................... ��YYuR1. ... ... ..... !.. .......................... c. o v o v o v <br /> Zoning Admin tratoreC4 8 8 $, $ 8 N <br /> 'TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ,e construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> iplication before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> - <br /> I a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> ound to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adromistratr <br /> '-.R SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />