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Burnett County Office of Zoning Administrator 47 -04 <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT I 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and }z n 1 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m r� SLS <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws the <br /> 3 <br /> regulations of the State of Wisconsin. ^_ a '• <br /> LSA r� <br /> ........ ...... ..t. .t........ ................... 12 n <br /> ............ . . . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT Ir � <br /> ADDRESS ADDRESS l m1131Q <br /> .y!. ... .....................................................................................i...... L €� <br /> ..... . . . 11 v <br /> ADDRESS ADDRESS �� 1 <br /> :v1\ <br /> ............................................................................... ...... <br /> PHONE PHONE <br /> ' 1 <br /> �Q <br /> PLUMBER � WELL DRILLER <br /> ................. o.!J......... 7 -�. .................... ..................................................................................... ...... o <br /> ADDRESS ADDRESS f n .o r <br /> +. 0 <br /> ................ !.�...........I�C(......�.5�....5.................. .....................................................................................(...... <br /> PHONE PHONE Z w r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> sth <br /> Baroom •� <br /> 1. Work: 2. New Building Details No. o <br /> New Building .......... Type of Construction: No. Bedrooms .......... kA <br /> Septic Tank Size Gals. <br /> Additionst .................................................... <br /> Sanitary ...r.�.,. Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> G Soil Type .............$ !`.':: . ....... ` jF <br /> Moven .......... Area ........................................... <br /> Mobile Home SIOPe .................s ...�0...... (w,J'. - <br /> Privy .......... 3. Use (describe exactly, -family Perc. Rate ..................r,�.,. ....... <br /> Well .......... home garage,motel, etc.) Dry Well .. _ <br /> 9 9 �....... Z i� 1 <br /> subdivision .......... Seepage Trench .. ....... <br /> .................................................... Privy <br /> Camping Unit <br /> Seepage Bed �$ >t. .J.•• � : . <br /> ----------------------------------------------- --- -- � c <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. AFL. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ------------------------------- — <br /> 0. <br /> ---- ------------------ —Location: t,Jli�E? c E <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ...«U.. ft. x ....�5�ft. — sq.ft. . <br /> ............................... ...................................................................... ........ .1 <br /> T y <br /> N o <br /> ° <br /> jj <br /> �:✓ o <br /> f <br /> 1 � <br /> r m <br /> Z <br /> Pk (AJ � _ <br /> � N � <br /> a =. ud $ Cm � <br /> m, Na� — am as A <br /> O0 •c ° me° <br /> Non <br /> n <br /> $ c o RI <br /> n <br /> r, <br /> a <br /> Signature of Owner or Agent Date <br /> Remarks .. ; <br /> o .. <br /> � H <br /> cn <br /> O . p <br /> ................................................................................. .. q <br /> �l�L'/ A N N N m <br /> ... .............................. .. .. <br /> Inspection Date ....................................... —..... �� $ 8 $ $ $ w <br /> c j Zoning Ad istrator <br /> e <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cihties before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans ol specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />