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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < — :'gynp <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 regulat�q, of the State of Wisconsin. 3 0_ <br /> K's.� a. .. .... T....................................... ............................... .. .... ...'.......................................... <br /> .. <br /> OWNER (please rint) CONTRACTOR or SURVEYOR or AGENT a :0� <br /> .1¢ ..�.�..... .«!cT.......... o, 1 <br /> ............................................................................................ <br /> ADDRE • ADDRESS <br /> ........... .1c.h�Sl � .....N!1...h..........S..5..`��a..3...... ............................................................................................ <br /> ADDRESS ADDRESS ; <br /> :1 <br /> . . ..................................................................................... ............................................................................................ \ l <br /> PHON PHONE ' <br /> .................................................... . .......................................................................................... ' <br /> PLUMB�R WELL DRILLER "\ <br /> ..... . ................................................................................... ............................................... ................................... _ <br /> O <br /> ADDRESS ADDRESS tL. T;',,r � (n n 01 <br /> 1 \ o o <br /> SA V <br /> » < <br /> ........................................................................................... <br /> .P.......................................... ................. o' <br /> PHONE HONE Z <br /> DESCRIPTION 4. Sanitary Facilities: o 0 0 <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details "" o <br /> New Building No. Bedrooms ' <br /> .......... Type of Constr ction: . ...... m <br /> Addition ..... Q,,, ., ,,, Septic Tank Size Gals. .� r \ <br /> ....... ... .. . <br /> Sanitary ... ...... Size ..oZ.. ..... ft. x ... .. .... ft. .. .' .. ..� <br /> Filling/Grading 4a. Absorption Field Site:... ...... Height............. Stories ............... <br /> .............. r i <br /> Moving .......... Area ................................. Soil Type ...................... <br /> o <br /> Mobile Home ........ Slope .......................................... :C7 .. <br /> .. t Pero. Rate ................................... <br /> Privy �r 3. Use (describe exec y, 1 fam�.r —� <br /> Well ... home,garage, motel, Dry Well ter-- • 9 <br /> .. .......... 7 i� <br /> Subdivision Seepage Trench <br /> Camping Unit .......... .................................................... Privy <br /> Seepage Bed /.�..... r � ,c: <br /> --------------------------------------------------------------------- `�.. � <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. It property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING C� <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. S_ ;Q or- <br /> ------------------- --------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... i '.; ,•1 <br /> .. m <br /> n <br /> o <br /> Q r ( 0 <br /> w <br /> t 3 � <br /> a t <br /> w <br /> 0114 <br /> 0 <br /> o � <br /> v <br /> 1 � <br /> 'G <br /> 7a f/1 r 9 u tar Crr < m <br /> Z ca o - _ <br /> 0 <br /> _ � a m <br /> Sig ature of Owner or Agent Date <br /> X�, m <br /> Remarks4. ././. Q'... ..a'!Z.':�al.""........................................................................................................................_.. <br /> m <br /> n <br /> ................... ............. <br /> ........................................................................................................................................... — <br /> / . <br /> ............. X'� / L.. :..:U-.fQ7fr..E..............I.................. .... ................ ....... ........................ . . . . . T <br /> Inspection Date L.....X......r�............. ..L....:...... .... .......... Cc N ro ro y <br /> m <br /> ........... <br /> Zoning Admin iSfrator �J $ $ $ $ $ $ <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 most 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 budd- <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 I>e made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />