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f' <br /> Burne t Court . <br /> • Y , <br /> Office of Zoning Administrator Cl) � o z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT T' 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as Q., <br /> o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a XS <br /> Jim N. Childs ON / prr d 0 <br /> OWNER (please print) CONTRACTOR or SURVEYORCUIY co {q <br /> 130.1.2..Shady..Dal.e..Rd. SCAINE Q <br /> ADDRESS ADDRESS °3 '4 C-, <br /> Minnet�anka,..MN 55342 F� <br /> ADDRESS ADDRESS 's\ <br /> PHONE PHONE <br /> C) <br /> H. <br /> Donald..Daniels i� a <br /> PLUMBER WELL DRILLER "N. to <br /> Box...W....Siren,...WI 548.7.2 N o <br /> ADDRESS ADDRESS <br /> 715-349-5364 or 463-2333 �' -. <br /> O N . <br /> PHONE PHONE Z N <br /> DESCRIPTION 0 <br /> 4. Sanitary Facilities: • o ,- <br /> 1. Work: 2. New Building Details No. Bathrooms ....1.... 0, <br /> New Building Type of Construction: No. Bedrooms ....3.... 1 , -°a <br /> Addition Septic Tank Size Gals. <br /> ....X.... I000• ,F < <br /> Sanitary X,,,• Size ft. x ft. p <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type r. n m <br /> Grading Slope 0 �0« <br /> • <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate 3.... <br /> Privy home,garage, motel, etc.) <br /> Dry Well p <br /> Well Seepage Trench 0 <br /> ""sl' I'e"famii home -C. ' <br /> Subdivision - <br /> y Privy - <br /> Seepage Bed ....X <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road C7 c {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- P N a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING 9J H. < <br /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 5. Lot Size: Fig. A. 6. Location: . <br /> ft. x ft. - sq.ft. <br /> CD <br /> Cl <br /> N O' <br /> o <br /> 7 <br /> 5 I\) <br /> See attached o N <br /> '-F <br /> V O <br /> 3 <br /> k -5. <br /> m - <br /> z <br /> 0 <br /> Do <br /> a, <br /> m <br /> i Lc <br /> CD <br /> •Vl <br /> 70 NI- 7 oz <br /> c n, 111:. <br /> m co <br /> co. N Q Q-<< CL <br /> -5 of Z. C ' C 13 <br /> O N N G m <br /> Z OO 'D : m X1 <br /> •o ii9 O E. E <br /> 01 um ...� <br /> k`O O <br /> c xi <br /> Q d� �-0 m <br /> t���l <br /> Signature of Owner or Agent Date o CX — <br /> Remarks.. ..),4/ ��' rn- 6 3 y 9 r m <br /> CD <br /> te <br /> int II <br /> Ni <br /> Inspection Date) - k P in .2 t-4� Ve .Jinn ,� 0 0 0 o ccs-i m <br /> Zoning Add�strator� J coo o o Cr)m <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> kefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />