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Burnett County Office of Zoning Administrall or Jg <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT <br /> J <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q .. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> re ulatrI'ons of the State of Wisconsin. <br /> OWNS Iplesse print CONTRALTO or SURVEYOR or AGEN <br /> f' <br /> �...... a� ... ...P...P.. ? .�i ................. ......... ............�..//.17.n �1.//SLS/.. f.� ..'....... ..... - <br /> ADDR ADDR 2SS / <br /> 1 <br /> -� � .................. ..... : <br /> AD RE f ADDRESS I <br /> PHONE PHONE <br /> y .................................. . . ............................................................................... ..... <br /> PLUMBER WELL DRILLER , <br /> p 7 <br /> ...... ..... <br /> .................................................................... . ............................................................................. . _. <br /> ADDRESS ADDRESS n O <br /> ........................................................................................... . ................................................................................... ...... <br /> PHONE PHONE a <br /> DESCRIPTION 4. Sanitary Facilities: <br /> y ; <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... <br /> Now Building .... Type o nstruction: No. Bedrooms ... ...... ; <br /> Addition 4^t�L -4Z Septic Tank Size Gals. ... ...... <br /> .......... ..........^.............. ....... . - <br /> Sanitary .......... Size .ol...�... ft. x ..K.G..... ft. ... ...... i . <br /> Filling/Grading .......... Height............. Stories ............... <br /> 4a. Absorption Field Site: <br /> SoilType .................... .. . ...... i,Moving .......... Area ........................................... Slope .................................. . <br /> Mobile Home ro <br /> i <br /> Privy .......... 3. Use (describe exactly �i -family Perc. Rate ............................ ...... m ?� <br /> , <br /> Well home,garage, motel, etC.l Dry Well Z >7 <br /> Seepage Trench ... ...... o <br /> Subdivision .......... . .................................................. <br /> Camping Unit Privy ... ...... <br /> .......... .....................I.............................. .>i� vim• <br /> ------------------------ Seepage Bed------ -- .N •N `TM� <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at �. <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ '.�` o <br /> ------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ....................................................................... ....... <br /> Mlit <br /> N O <br /> O l <br /> If o <br /> T' f <br /> v <br /> r <br /> lif �ara OwYo <br /> r_ <br /> l,i A <br /> .I � a <br /> D � <br /> �, _. m <br /> m NC`iay ''- aM aay <br /> O<_ d C N n 0 F. <br /> O in 1 p n n <br /> Z_O Q D 1 <br /> N N a A <br /> '0 c " m <br /> a : 0 : O <br /> S <br /> ........... ........ ..r.. . ... <br /> m <br /> Signature f Ow er ge �DatE e <br /> N <br /> T Q . <br /> Remarks .................................................................................................................................................................. ...... <br /> ................................................................................................................................................................................. . <br /> ...................................................................................................................................I............................................. ...... <br /> ..... '•J N OD N r N rn <br /> Inspection Date ....................................... ' !' J' '........� i/t(:.f i............. . 8 8 8 8 8 tmis <br /> Zoning Administrator. <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap lication 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans 01 specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />