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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . :\ <br /> o :� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as v Z <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. 3 a <br /> 0 <br /> . *Fp ' .Cr.. . oAJ..................... . r. .k:✓..,.,..... usf............................,.. N <br /> a <br /> OWNlease print) CONTRACTOR or SURVEYOR or AGENT " <br /> (,,,1.......LI..1�.... ....................�1 e'.r..45.: ... 1. ?.2-. ......At1...,�, 0.�.!1.�........���a:h.d....4.A � <br /> ADDRESS C ADDRESS <br /> w.......... .............. ......... .1... .. ........Baa.z.3.................................. � <br /> ADDRESS ADDRESS <br /> y <br /> ..... <br /> �r�.1.. ..-.r(./. ...7.............................................. n" <br /> PHONE PHONE �p ; <br /> ' ni <br /> PLUMBER WELL DRILLER � � <br /> ........................................................................................... . ..........RES................................................................................ <br /> ADDRESS ADDS l 0 o S> <br /> M � <br /> .. ........................................................................................ ............................................................................................ 0 <br /> PHONE PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: I ° o <br /> 1. Work: 2. New Building Details No. Bathrooms :w. c <br /> New Building .......... Type of Construction: No. Bedrooms .. t z <br /> �� �C r Septic Tank Size Gals. <br /> Addition �!!`!:\+.>?.:°-............. <br /> Sanitary Size ..... ft. x ...../..V... ft. ✓ E( <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving Area .................................. Soil Type .................................... r i <br /> ........ <br /> Grading .......... Slope .......................................... :?) <br /> Mobile Home .......... 3. Use (describe exactly, -family Perc. Rate ................................... r1= 't c <br /> Privy y I <br /> ,,,•,,,,,, ho��gqe,garage, motel,etc.) Dr Well .......... I '� <br /> Well j59 Seepage Trench .......... iA - <br /> .......... .................................. ................. :n <br /> Subdivision Privy . .. <br /> .......... , t T <br /> Seepage Bed / , <br /> —————————————————————————————————————————————————————————————————————— v� <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road ,� a :c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- r j _ C• <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. <br /> ) p <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: J ;4 i <br /> XRA...... ft. x .r�.Sr...7. ft. — sq.ft. <br /> Y <br /> N O <br /> 0 3 <br /> vJ O <br /> t <br /> S <br /> ID <br /> I f ` 21 <br /> it` ZI <br /> /c r <br /> d <br /> �' m <br /> 'L- ?� <br /> tnr �� Z <br /> -------- m N G CL<19 <br /> m <br /> 2 <br /> o 00 <br /> �� 3 <br /> 14A 0 <br /> Signature of Owner or Agent Date <br /> P� X <br /> Remarks . .. ...C.11 ....................................................................................................................... ' M <br /> ..............44. ............................................................................................................ <br /> .I <br /> a : <br /> //- 3 J 00000r�m <br /> Inspection Date ....................................... � . ....../�dmin�istrato**r** <br /> Zonin o 0 0 0 0 o N <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 must 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 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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />