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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. _ a <br /> 10. j; ..Q.... ... ..,Q.Qf7?.+n..4A1.f. .............. .............. _ <br /> n <br /> OW ER Ip ase Printl t/ CONTRACTOR or SURVEYOR or AGENT <br /> .. � W .� <br /> ADrS 9'7 <br /> �� ADDRESS _ <br /> Cn.... ......... 3..-5...�.�..�j.... ........,................................................................................... i <br /> ADDRESS --� � �� ADDRESS i <br /> .............. .... ..... ...................................................................................... <br /> y .... PHONE <br /> PHONE El <br /> ............. ..................................... <br /> ........................................................................................... . ....................................... . <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . ......... .............................................................................. •� <br /> ADDRESS AD.. DRES..S � C <br /> .................. ................................................... <br /> ................ <br /> .P.H..ON....E............. . •� <br /> PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 1. W Q 2. New Building Details No. Bathrooms <br /> New in fQ Type of Con truc ion: No. Bedrooms ....... [ <br /> Addn� """fi' � Septic Tank Size Gals. <br /> Sanitary .......... Size ..:. ;.. ft. .......... <br /> Filling/Grading ,......... Height..... ... Stories ............... 4a. Absorption Field Site: <br /> r.................................... `: E <br /> Moving .......... Area ........................................... Soil Type <br /> .......... o <br /> Mobile Home Slope ........................... ......... .... <br /> y <br /> .. Parc. Rate .................... . . . <br /> Privy 3. Use (describe exactly,'1 -family "" o <br /> Well .,........ home,garage, motel, etc.) Dry Well ......... m <br /> Seepage Trench o t� <br /> Subdivision ' <br /> .......... .................. <br /> Camping Unit .... Privy .......... . <br /> Seepage Bed .......... :Jl.l <br /> ---------------------------------------------------------------- ---- I c <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. <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 intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------- _ __--____5. L Size: Fig. A. 6. Location: -cs-c7 <br /> ./.�1J...... ft. x ', i�.Q..Lf... ft. — .... .Q�.0(1 U..... sq.ft. ......................`. .a... .. .. . ............ U i <br /> 7S F <br /> s <br /> � v <br /> let 0 <br /> Ill Z Z <br /> o co <br /> mvf� r Dm m rn <br /> 7 m c o� d o c c m <br /> od'v < � o n � <br /> T <br /> oo< ; iv co 0 � 3 <br /> Z^q O D 1 <br /> c o 20 m <br /> 7T rn <br /> /� --- — — <br /> 0 <br /> tF <br /> ......... . . <br /> of Own r oi�gent t/ Date <br /> 0 <br /> m <br /> N <br /> Remarks <br /> N <br /> .........................................................................................................?val <br /> ..................�./I^I../' ... ............. <br /> ......`........... O <br /> Y '..... N N N O <br /> InspectionDate ....................................... .. . . .................i..*'..(�........ ......., <br /> Zoning Administrat r X111_ g g g <br /> NOTE: A preliminary site inspection must be made and site appynted on all structures involving sanitary facilities 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 or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />