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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> _ o :➢j <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as m ;d <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. <br /> ?:�1... .......LE.o.nFn. ............................ . .......................................................................................... <br /> F ° <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> tia <br /> a <br /> ................................................... .... . ....................................................................................... d <br /> ADDRESS <br /> t.....1.. ..................................... .ADDRESS............................................................................ <br /> ............................................................................................ <br /> PHONE PHONE <br /> ` ..T.. .. !1...�. ...................... .......... <br /> PLUMBER WELL DRILLER <br /> � T <br /> ADDRESS ADDRESS :Vx n o <br /> ........................................................................................... . ................................................. ....................................... � o' <br /> PHONE PHONE Z � r <br /> DESCRIPTION 4. SanitaryFacilities: P o ° :F, <br /> 1. Work: 2. New Building Details No. Bathrooms ... o <br /> New Building .......... Type of Constfuct' r No. Bedrooms ... .. ,� <br /> ! r K Septic Tank Size Gals. ........ <br /> Addition .... ........`- .....��...... <br /> ........ 00 i <br /> Sanitary .. .. Size .............. ft. x .............. ft. �...... N �y <br /> Fillinglcrading .......... Height............. Stories ............... 4a. Absorption Field Site: :I r!^ f <br /> Moving Soil Type ................................I... r <br /> .......... Area ........................... ............... o <br /> Mobile Home .......... Slope .......................................... -a <br /> Privy ,,........ 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Dry Well <br /> Well home,garage, motel, etc.) """' " iZ <br /> Subdivision Seepage Trench .......... i :a <br /> Camping Unit .......... .........................:.......................... Privy .. � :• <br /> Seepage Bed �.�r-.•"" lil :T <br /> ---------------------------------------------------------------------- <br /> O N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road n <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If 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 :O = <br /> `^ N. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------- _--__---_ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> e <br /> m <br /> Lt <br /> N s :I" OK <br /> 4- it <br /> .� :'X- <br /> 13 <br /> ti -r T <br /> • " o <br /> Z Z <br /> F ` ° <br /> ,y �• rr1 <br /> In r 9 w Z <br /> m m m <br /> m N < <br /> c <br /> m : m <br /> o <br /> Z �^. y n <br /> O o <br /> in <br /> 0 <br /> v M <br /> . . .�........ ... o C <br /> Signature o'Willf Owner or Agent Date 70 <br /> X <br /> m <br /> Remarks ......................................................................................................................................................................... m � <br /> .......................... tst . <br /> �... . <br /> II <br /> j? <br /> ................................ i E �;t /.� GQ2 i. ... ................ y' <br /> . .... ........................................... 1 N N b! N m <br /> inspection Date 1 �..�.. Ja..— .... `hi fn o o 8 o to <br /> p .. .......... ............ g .. ... ... ... . .........I.............. o m <br /> Zonin dministrator $ 98 8 8 y <br /> NOTE. A preliminary site inspection must be made and site approval granted on all structures Involving sanitary facllitieS <br /> before 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 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 lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />