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G" <br /> Burnett County Office of Zoning Administi ator �' c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and '2 :. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements c f the ,: Kj\ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and <br /> regulations of the Stateof Wisconsin. 3 <br /> f..l .a.Ari/td.... ... 1 .�i.t...... ......... .. ..ti ........................................... ... . . . ......................... ....... n <br /> OWNER (Please print) CONTRACTOR or SURVEYOR or AGENT o <br /> ..S.I.-AR..t.'...........f <br /> ADDRESSb x !ala:s ........................ . . . .. . . . ................................................................... ........ADDRESS n :fit` <br /> :}- <br /> m <br /> ADDR ......... ...... . ....J.. .. .. ..... .......................................................................... ........ <br /> ADDRESS _ <br /> ............ . .S-.. .. ...! .' ...............I.................... <br /> PHONE . .......................................................................................... <br /> PHONE <br /> ........................................................................................... . .............. 'lam <br /> :1 <br /> PLUMBER .................................................................... ....... <br /> WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .................................................................................. ....... <br /> ADDRESS <br /> O <br /> n <7 <br /> PHONE . ...PHONE...... . ....... <br /> ...................................................................... .. � ,.; <br /> .--.•'. � ' . <br /> DESCRIPTION e o <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2 Bw4dieg.DateHs No. Bathrooms .. ....... i Is <br /> New Building Ty of nstructi n: No. Bedrooms .. ....... o <br /> Addition Septic Tank Size Gals. R . <br /> x... �. .. . ................. .. r; <br /> Sanitary .......... Size ft. x .....N.. ft. <br /> Filling/Grading y 4a. Absorption Field Site: <br /> .......... Height............. Stories .....1......... P <br /> Moving Area Soil Type ............................ ....... r <br /> ho e,garage,motel, etE) , . <br /> Mobile Home Slope .................................. ....... •l. <br /> Well <br /> Privy i g g exactly, <br /> <family Perc. Rate ........................... ....... d i o !3 <br /> .......... 3. Use describe exactly,'t -fam <br /> jj" <br /> r�1 y i <br /> CampinSubdivig <br /> L1. .... N PrivySeepWell <br /> ,,,.,-.., -0 <br /> .......... f`�f�lJ<d a Vtr!, f <br /> --Cam Ding Unit_ .. f Privy <br /> .......... ........ .... .. ...... Seepage Bed ..... <br /> Location of proposed structures and existing structures well sewage systems, roads etc. should be sketched in Fi . A. I -� <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at i <br /> a highway intersection, show the intersecting highways and the setbacks required along them antl at the intersect it . <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Uj <br /> T. <br /> p _ n <br /> rTCF.�♦=5 Fig. A. 6. Location: - � � I i <br /> 5. Lot Size: y�,� I <br /> ft. x .............. ft. — ............................... sq. ft. dJG1.1.Q1.. v-f Q <br /> i <br /> fV 0. <br /> O > <br /> J <br /> J ,O <br /> � �o' Loi L ,�� 0 <br /> O <br /> 0 <br /> ry <br /> t <br /> mv (nr <br /> m <br /> nd'c < _> > m <br /> N <br /> A. Ut d ' dry d M <br /> m 3 <br /> ON O m <br /> O W O D 1 <br /> 11711 <br /> .. '!:G4xa1 Y !-"Y... ............. —/ / 4v <br /> Signature of Owner or A ant ..........11......V..""-""""- A G <br /> Remarks1� .. T y <br /> / .............. ....... .... ....... m ,. n <br /> m . <br /> ...................................................................................................................................................................................... . w <br /> � o <br /> o : o <br /> .................... ................................................................................... in <br /> _ <br /> Inspection Date N m Nc In <br /> ....... . ..... <br /> ZoningAdministra r $ $ $ g N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construct <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit I <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been i sued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or sp cifications 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 />