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Burnett County Office of Zoning Administrator d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H ° :-Z3 <br /> � acv, <br /> N v <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> ~�) <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> 11f.. ... ................................................. �I .......... <br /> . l �.... . .............................. N _ <br /> OWNER (please print) CONTRACTOR or SURVEYOR o AGENT c i <br /> rc�.e �s1 ....... :.vy 3........................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> ADDRESS .ADDRES.............S............................................................................. � <br /> ........................................................................................... ............................................................................................ <br /> PHONE PHONE <br /> ........................................................................................... 1 <br /> PLUMBER ............................................................................................ ;t�V <br /> WELL DRILLER <br /> p <br /> ADDRESS ADDRESS <br /> n ° <br /> ........................................................................................... " < <br /> PHONEPHONE.......................................v....................................... � o •: <br /> DESCRIPTION 4. Sanitar Facilities: ° o K <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New BuildingNo. Bedrooms <br /> .......... Type of Construction: <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... 2 <br /> Sanitary .......... Size ft. x ft. •..•.•.••. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area .......................I................... Soil Type .................................... r <br /> Mobile HomeSlope <br /> .......... .......................................... <br /> Privy .......... 3. Use (describe exactly, i -family Perc. Rate ...........................I....... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision �/ Seepage Trench .......... <br /> .................................................... Privy <br /> Camping Unit ' <br /> .......... .................................................... .......... <br /> Seepage Bed .......... `• <br /> --- ---------- -------------- to <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig_ A. Include road ° <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STH UC TU RES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> —.----------------------------------- -----------------------------_---- J i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> Ld <br /> �j]/q/ r N ° <br /> Pa O <br /> 0 <br /> o� <br /> g r <br /> c? c `C <br /> z � <br /> (D r <br /> J <br /> MN r v m m z <br /> rp C <br /> m on°- n.e d o 1p <br /> a (.n <� C � ro c -0Z b D a m <br /> o0.1�� am <br /> ') o <br /> .. ..-/D 0 <br /> ..................... 'w"'n'..............."t.............................. . ....................... o C_ <br /> Signature of Owner or Agent Date <br /> Remarks X <br /> ......................................................................................................................................................................... �' Ja m <br /> v <br /> .................................................................................................................................................................................... <br /> .........................................................I...... <br /> . ................ <br /> Inspection Date ZO �-;i <br /> N ro c m o m <br /> ....................................... ... ............................. . . ........... . . . .................... n urn a <br /> Zoning Administrator . e $ $ $ $ $ $ f� <br /> NOTE. A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test most be 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 budd- <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 Adm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />