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C17 Vic' 3Z7� <br /> Burnett County Office of Zoning Administratoru 0 0 <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 'c <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use ; <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> VfIN...��......... ............... .ft. u.s:oy.......... ........................................................................ N <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT o. <br /> f ..�............1 ..................................... ... ........................................................................................ � <br /> ADDRESS ADDRESS » i <br /> / L`.6UR.X..............w>...........z�'�'�'3Q. ............................................................................................ <br /> ADDRESS ADDRESS <br /> ............7../..1"......15 ..."...7... .` .Y............... ............................................................................................ <br /> PHONE PHONE ;O ? <br /> WELL DR"Ll, ................................................................. V <br /> PLUMBER I ; <br /> ADDRESS............................................................................ .ADDRESS............................................................................ L <br /> ci <br /> o' <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: 0 8 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building ., Typ of o struction: No. Bedrooms .......... r4 L <br /> AdditionE Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .. .�.. ft. x .... .Y...•ft. """"" <br /> 4a. Absorption Field <br /> .... Stories ...............Fillip rGrading Height Site: '. <br /> 9qt,/ [ <br /> .......... Area ..�.,C1.."G.�...,F.�s...F.T.:... . . <br /> Moving .......... of Type .................................... . . o <br /> Mobile Home Slope .......................................... » <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... i <br /> SubdivisionSeepage Trench .......... <br /> .......... ......... ... ........ ... .. .. . y . <br /> Camping Unit .......... G <br /> Priv .......... (p <br /> ....... . . .. .....Ci. . . A. .......... p <br /> ee ag e Bed ......... ,w <br /> (A <br /> ------------------------------------------------------------------ <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 14) Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If properly is located at a highway inter- t a; <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING n. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 'v o <br /> ------------------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: w M <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> a <br /> n <br /> N O <br /> O = <br /> _ <br /> 0 <br /> j 0 <br /> 0 <br /> z <br /> O <br /> uv '� T <br /> M n r v :k y m <br /> m die <br /> 77 <br /> Z <br /> � H .gym = <br /> Da <br /> oo . a � <br /> o = a <br /> f , ^ 111Sigggllh�iature of Owner A ent Date X <br /> Remarks ......................................................................................................................................................................... m m <br /> v <br /> .................................................................................................................................. <br /> o: <br /> : : : <br /> Inspection Date ....................................... .1.272K.2../...:.....,1.. x6 ...�:✓................ E log p u 8 o U m <br /> Zoning Adminisrf atch <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 attacher) 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 />