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Burnett County Office of Zoning Administrator c o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. D <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as rn o <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 /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. g o. <br /> OWNERMO /4 S749 Ai`t-, 7 F.,,, <br /> •• ,, (p rio se t) ` CONTRACTOR or SURVEYOR or AGENT a - <br /> ru <br /> ''``' r� Fr, <br /> to S (..A) ADDRESS °r+' <br /> ADDRESS ADDRESS ,k) 7 a <br /> PH ^ PHONE ,� °�D •` � <br /> 14-to k th s ,l'`) ,C <br /> PLUMBER WELL DRILLER <br /> en <br /> °N-1 v <br /> ADDRESS ADDRESS m G) <br /> o ..ii. <br /> c <br /> o' r+ S <br /> PHONE PHONE <br /> z 'n r r <br /> DESCRIPTION 4. Sanitary Facilities: t . o ° <br /> 1. Work: 2. New Building Details No. Bathrooms U1 C <br /> / <br /> New Building Type of Constr4t;An: No. Bedrooms <br /> Addition k--5?.,,)Ct T f (4i g Septic Tank Size Gals. S`� , < <br /> Sanitary „dC Size ft. x P ft. <br /> Filling/Grading Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type or <br /> Mobile Home Slope �-- <br /> Privy 3. Use (describe exactly, <br /> Perc. Rate <br /> Well home,garage,motel, etc.) Dry Well �._ <br /> Subdivision Seepage Trench <br /> Camping Unit Privy A� <br /> Seepage Bed W../a x�O & { <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> 1 N <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- . _E <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING f <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 5. <br /> 5. Lot Size: Fig. A. 6. Location: ^' F <br /> ft. x ft. - sq.ft. <br /> 4 <br /> cn <br /> `r, CI <br /> N C' o <br /> O -) 7 <br /> jj O <br /> }j o �r <br /> -\ FrY <br /> yJ 0 <br /> cn <br /> Th A <br /> 1:, , <br /> ..__ _ [ z <br /> 0,3 <br /> i)) ...... .-, . 4‘ <br /> CO <br /> CD <br /> yk‘1, '''It' 15' . <br /> m ke 617 < m ; Ca' <br /> . -5 0-1. w _, cc .O <br /> n <br /> r+ o ; m �Darll <br /> OZ o o a 5 77 <br /> • EA _ rc C <br /> o <br /> ,r 4 o <br /> dn1 a <br /> Signature of •�/ner ora Agent Date W 5)-: <br /> X 7)Remarks de/i1I ��- "" - r <br /> CD CD <br /> � N IIyr '�C ".(.% H <br /> Ie <br /> Inspection Date � �� g ° -n <br /> nmo Nan o CD o <br /> Zoning Administrator 'C J ObbOO o 0 0 0 0 o N <br /> -E: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> 'Instruction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> .:\ ion before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> it has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> 'st. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> EM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> i <br />