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Burnett County Office of Zoning Administrator o CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' 3. <br /> o <br /> TO TIME ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N- -' eSU <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use cco e <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- .' <br /> o <br /> Milton Potter <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENCD <br /> T <br /> 12625 S. 100th Ave. a : <br /> ADDRESS ADDRESS m rt 3 <br /> Palos Park, IL 60464 H. <br /> ct <br /> ADDRESS ADDRESS �`sg 0 <br /> -- 4•Y ; Ili <br /> PHONE PHONE 'C/ N` 0 <br /> ct <br /> Donald Daniels • n- <br /> al <br /> PLUMBER WELL DRILLER . I <br /> Box W Siren,, WI 54872 N 0 <br /> ADDRESS ADDRESS '.0 D G) <br /> 463-2333 or 34.9-5.3640- 4- <br /> PHONE PHONE z N • <br /> DESCRIPTION 4. Sanitary Facilities: o. o . <br /> 1. Work: No. Bathrooms t) v <br /> 2. New Building Details i o <br /> No. Bedrooms ..4 '3 <br /> New Building Type of Construction: -, F <br /> Addition Septic Tank Size Gals. 12.00 , 0 <br /> Sanitary X Size ft. x ft. N <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type 0; V <br /> Grading Slope to ° <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate l <br /> Privy home,garage, motel, etc.) Dry Well .j b <br /> Well Seepage Trench 0 co <br /> Subdivision single family home Privy <br /> Seepage Bed $ <br /> J <br /> cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road Vd . O <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- "d _Q <br /> • <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. H <br /> V. O <br /> 5. Lot Size: Fig. A. 6. Location: 9- W <br /> ft. x ft. — sq.ft. 6 <br /> P <br /> cn <br /> 0 0 <br /> N 0 O <br /> o O <br /> W N <br /> 0 a'() <br /> C" <br /> ". ) 0 <br /> 0 <br /> See Attached drawing OS „ o <br /> cil z <br /> z <br /> 0 <br /> v <br /> 0 <br /> CA m <br /> IV --'h <br /> lUl - ' <br /> I <br /> ,s. -S <br /> z <br /> � C E � . cc <br /> C) �67 N E. <br /> � C NQQ. G — a' <br /> Y1 -3 cT <.0 3. C) 'O <br /> u '* O N .., to * m <br /> O 0 ? <br /> om CD Xi <br /> 01 CO' E <br /> (310 -I <br /> Q r�vo xi <br /> ,Ata."60 'I� � � m <br /> Si nature of Owner or Agent Date <br /> o • C <br /> Remarks -� f= I*-" 4t//314 I <br /> T X lam <br /> CD <br /> CD <br /> It <br /> u <br /> DO VI' <br /> Ins ection Date pa„...0, ,,e27,4„4„..e.,,,- <br /> J oo0 ocnm <br /> p Zoning Administrator J 0 o o o o cmit <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> oefore 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />