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Lam �c,�o y0 <br /> Burnett County Office of Zoning Administratoro Z <br /> 0 <br /> ' <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ;w3 , <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� _ o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with <br /> all other applicable County Ordinances(and the laws and regulations of the State of Wisconsin. 3 c'- <br /> ......................... <br /> :O <br /> .....1.!k!..ri'1,A.S........W ` Int r•'.:D4�. ............................. . ............:'...... ... ..... a." ..5.. ............................... '^ O <br /> OW R (please print) CONTRACTOR or SU VEY r AGENT a M <br /> ..............................t.......... . ..�.. ................... . .................. ..... ...�.....�............................................. a <br /> AD RESS ADDRESS <br /> ........... ti. ........'tiH .►ti.,..............ssr.!.o.... = <br /> o :o <br /> ADDRESS ADDRESS <br /> ..................................................................................... . <br /> ...... <br /> PHONE . ................................................................ <br /> PH..ONE....................... <br /> ........................................................................................... :� <br /> 'W—........................................................................................ <br /> PLUMBER WELL DRILLER <br /> ADDRESSADDSS <br /> RE ....... <br /> ...... <br /> ........ <br /> ..... <br /> ............. <br /> ............ <br /> ............. <br /> ............. <br /> � v <br /> 5 <br /> m C7 <br /> 0 <br /> ........................................................................................... < <br /> PHONE <br /> DESCRIPTION o H o :.0 <br /> 4. Sanitary Facilities: o � <br /> 1. Work: 2. New Building Details No. Bathrooms .... -o <br /> New Building x T No. Bedrooms .... .. \ EQ -Oo i <br /> Type of nstruction: <br /> Addition PQ/W Septic Tank Size Gals. .......... <br /> Sanitary „xSize .A.f..... ft. x .�..�it..... ft, <br /> Filling/Grading .,.,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> zl. <br /> Moving .......... Area Soil Type .................................... <br /> ........................................... <br /> Mobile Home .......... Slope .......................................... � 0 <br /> 'O <br /> o <br /> I <br /> Privy 3. Use (describe exactl ,;1 -family Perc. Rate ................................... <br /> Well .,<... home,garage, motel, Dry Well .......... w ;� <br /> Subdivision ........ .................................................... Seepage Trench .......... i <br /> Camping Unit .......... ................................. Privy <br /> ---------------------------------------... ............... Seepage Bed �1 <br /> —————————— ——— <br /> --_--- 'VI- <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road �1 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a�V <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING `� 5. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: OJ Fig. A. 6. Location: 7 <br /> ...... ft. x 73........ ft. — ............................... sq. ft. ............................................................................... � <br /> T : — <br /> G.r ti« � <br /> s - 0 <br /> IS' <br /> 0 <br /> >9O J-0A <br /> 91 311, 010 f4,1T <br /> m O <br /> Z L <br /> 0 <br /> d <br /> m <br /> r a <br /> M <br /> fD. ME- <br /> Zo 0 <br /> D <br /> o 5 = n ' <br /> fn <br /> /0 4,T—(—IKI�41 <br /> po <br /> . ' : 77 <br /> pp <br /> `)........................ ...�.�..'... ......f......... �q s p <br /> Signature of ca�ner or Agent Date <br /> Remarks C��l.!.. 0 "C . X : m <br /> v <br /> ................ .. ..................................................................................................................... � — <br /> Ci3l\i <br /> Vii: `..............:+......r................................................... ... .................. . <br /> Inspection Date �L.7 �� i c. — N — N m <br /> ///��J .... p . <br /> P ... . .........t'."..... .. ...... ...................... : I^: o o Q'n <br /> � Pm <br /> Zoning Admi strator 8 8 8 $ $ $ CO <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facllitwa <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 plumhing 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 />