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1 <br /> Burnett County . 'Office of Zoning Administrator M _0 <br /> 3 P <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 <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. 3 n. <br /> i�.�.... RA ...................................... .�r...ado.:......................... Nn o <br /> a <br /> OWNER (please print) CO TR CTOR S VEYOR er A T mIS 3 <br /> 1..4'.9.. 2..LD1/N..��FA.<< ..f.... -!`a-'........ .... <br /> ADDRESS ADDRESS <br /> .................. a q3 .............................�r <br /> ADDRESS ADDRESS .✓� Af <br /> .��.i>2..._A �3...-/r!/.......................................... .................................... ry .... � <br /> Y <br /> PHONE PHONE .•. .••.• ••'�.. QN _ •\ O <br /> �lsO.i11..................................... ......... .. . ...........p..r.....t....3.........` ..�....•.t....... <br /> PLUMBER WELL DRILLER <br /> ...Wr�sT�iq W i5:.s y9.. ........ , o ► <br /> ADDRESS ADDRESS o <br /> 7!s-86..-..Y..dss.................................... <br /> 0 < ;� <br /> ............................................................................................ 'z y <br /> PHONE PHONE 'M <br /> DESCRIPTION 0 <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms -u <br /> 2. New Building Details ••1••••• `'t v <br /> New Building ...X... Type of Construction: No. Bedrooms 2.. �1 m <br /> Addition ......W247.0...f, h.M� Septic Tank Size Gals. 11ki , of <br /> Sanitary3�.... ft. <br /> ..... Size ...�!f,.,, ft. x ... <br /> Filling Height............. Stgries ...l......... 4a. Absorption Field Site: <br /> Moving .......... Area 117M Soil Type �/11��. .................. . ? .o <br /> ff+�� <br /> Grading .......... Slope ...... ..Q....... ..................... :p <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ....................... N <br /> Privy ..• home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench <br /> Subdivision ......... Privy . ..... . .. <br /> Seepage Bed /2A 3s ........... <br /> ------------------------------------------------------------—"i ---- �> iy (n U: <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road U 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- a <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. ,.F {A <br /> H <br /> -------------------------------------------------------------- -- �1 <br /> 5. Lot Size: Fig. A. 6. Location: C <br /> ...�Z63... ft. x /.. y.... ft.�.-V lRak.16,.9.00.... sq.ft. ............................................................................... <br /> 2 C> <br /> m <br /> c <br /> 0 <br /> 0 <br /> o <br /> T <br /> A <br /> Z <br /> O <br /> d <br /> 40 <br /> C 7 <br /> y� <br /> ]1 Cn N co <br /> 60 <br /> C d <br /> ZO O m : m ]J <br /> O 2 <br /> O <br /> O <br /> w O <br /> �3 m <br /> Signature of Owner or Agent Date b , _ <br /> Remarks . S... ! .... U ...... /✓r ev! 3 T <br /> oag:8 / ...� .......................... X m <br /> . . <br /> ........................................................................................................................................................................................ <br /> ............................................................................................................. . ................. .. <br /> II <br /> ..... .. ......... ............................... ��-;___ilio' N <br /> 11�. . 6 T <br /> Inspection Date ....................................... o 0 0 o W m <br /> Zoning Admi Istrator o 0 0 o o 0 <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 />