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Burnett County Office of Zoning Administrator ? o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> J <br /> o <br /> TO THE ZONING ADMINISTRATOR The undersigned hereby makes application for a Permit for the work described and located as < m <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use pOQ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> K�u� <br /> L /A ..� Via.................... !G�............................ SE C �T' .. <br /> ... . . . <br /> . . . ...... . . ...... ... . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT n <br /> �>< .a1A <br /> . ...... ............:... ......................................................... <br /> ADDRESS ADDRESS <br /> . s76. .... .......... .. ............................ <br /> ........................................................................................... <br /> ADDRESS ADDRESS <br /> PHO...........E................................................................................ . ... .................................................................................. <br /> NPHONE.... .. ; p <br /> ........................................................................................... .WELL... . . DR. I.LLER. . . .................................................................... <br /> PLUMBER (,\ <br /> .......... o <br /> ADDRESS ADDRESS <br /> C) <br /> _. < <br /> ........................................................................................... ........ .................................................................................. o ,» <br /> PHONE PHONE.. Z H r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ."'.. o <br /> New Building ...x,,, Type of Construction: 64ieA6E No. Bedrooms .......... m <br /> Addition �> ��G;�l,•••...6, Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ....z. ft6 x ft. "'•""" <br /> Filling/Grading ries .......f. 4a. Absorption Field Site: <br /> ..... h •. • St <br /> , <br /> Moving Area .......... Soil Type .................................... <br /> .......... ... ............. r <br /> o <br /> Mobile Home .......... Slope .......................................... <br /> Perc. Rate ..................Privy .......... 3. Use (describeexactlY, 1 -familY ................. f]3� <br /> t <br /> Well .......... home,garage, motel, etc.l Dry Well .......... <br /> Subdivision C .............. ................ Seepage Trench <br /> .......... <br /> L: <br /> Camping Unit .......... Privy .......... W <br /> .................................................. <br /> Seepage Bed ........,. 2� <br /> ------------------------------------------------------------------ --- m <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched in Fig. A. Include road <br /> cr <br /> setback, side and back yard dimension and location and setback from all bodies of water- If property is located at a highway Inter- © i C1 <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection- CLEARLY LABEL EXISTING T < <br /> o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' , <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: / / Fig. A. 6. Location: X# <br /> .(/.1/.O. ft. x 4/..v0 ft. — ............................... s4. ft. ....... F.Y/...........^!' ....1.!�....�./#....... <br /> St G R� <br /> 0 <br /> Nz <br /> R� <br /> N rO 1Z <br /> O � � <br /> O <br /> 0 <br /> TJ: s <br /> i I � <br /> G (pru�n� <br /> re <br /> - ,/ <br /> (vf <br /> cr <br /> EH n - F <br /> C <br /> \ Z 0 o m D a <br /> C ] n <br /> r........rC. ...... <br /> Signature of Owner or Agent Date <br /> /v`� y� L / I^ ! C <br /> Remarks .` ....l.:t'17.1C(.,... 70 <br /> ........�(.Y�l-.l... ...... .�12......"l�...... � ��-� �I x � m0 <br /> ............ . ........................... <br /> m : <br /> ........................................................................................................................................................................................ <br /> II <br /> ....................................................................................................... .... ............. ........ ............................................. <br /> Inspection Date ....................................... m <br /> G .......................................,. U P o N far, <br /> T <br /> N <br /> Zoni Administrator 8 8 8 8 8 <br /> NOTE: A preliminary site inspection must be made <br /> 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 plumhing or start any bnlld- <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 he made without approval of the Zoning Administratol. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />