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Burnett County Office of Zoning Administrator VZ <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 o <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < 9" <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 ma N <br /> �% ...., fi % 1r�Y......... . ......................................... ................................................ <br /> WN6�W'l/please print) CONTRACTOR or SURVEYOR or AGENT a <br /> .........C.� <br /> 7 .....Gf/ VS� .............................. <br /> AD RESS ADDRESS ' <br /> T-�l92dC f/1iIs1/ ff7 <br /> ..............fi.. ................................ .. .................... ............... <br /> ADDRESS ADDRESS v <br /> .................. ..................................... �/ ......... . .......................................................................................... <br /> PHONEGv/ <br /> ` <br /> PHONE <br /> PLUMBER WELL DRILLER <br /> .................. E <br /> ......................................................................... . . .ADD.. ...................................................................................... <br /> � (�/\ <br /> ADDRESS RSSm •�0 <br /> n O <br /> PHONE.......................................Y.................................. � J » <br /> PHONE ""' <br /> r <br /> DESCRIPTION 4. Sanitar Facilities: �`�� ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms I <br /> New Building ....`..... T e of Construction: No. Bedrooms .......... 0 i <br /> Addition .......... Y�".q..... Septic Tank Size Gals. .......... o <br /> Sanitary .......... Size ......J.U. ft. x ...... :. ft. .......... <br /> Filling/Grading 4a. Absorption Field Site: �a- F <br /> .......... Height............. Stories ............... Nl <br /> Moving Area Soil Type .................................... �: <br /> ........................................... r <br /> .......... ^�' o <br /> Mobile Hama .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ........................I.......... :r <br /> Well ho e,garage, motel, etc.) Dry Well . .I...... <br /> OF W <br /> Subdivision .......... ,rr ,-�qR Seepage Trench .I........ o i <br /> Camping Unit ,,,,,,,,,, Privy ... ...... ' <br /> .................................................... Seepage Bed <br /> ...... .� <br /> --------- — w ? i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter p a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> -----_ ---------------------------------------------------- i <br /> 5. Lof,Si�g: Fig. A. 6. Location: tj <br /> ........... ft. x f�U.... ft. - sq.ft. o kA <br /> .. ............................... ............................................................................... <br /> !3 <br /> _ CC IN <br /> ' O <br /> "Ja [ Of <br /> d� t� - <br /> L.� <br /> xx <br /> 7 <br /> d <br /> . n <br /> v <br /> 77 (nr v � t m' <br /> m > C N <br /> _ E <br /> �• "O UI << C <br /> Z o o' n a <br /> on - <br /> m <br /> ....................... ..... / / b......... ut' <br /> � o C <br /> 'gnature of Owner or Ag nt ate ' » <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> 1D O <br /> ........................................................................................................................................................................................ to <br /> II <br /> ....................... <br /> :Ul <br /> mInspection Date ....................................... - - : '°: >r o o <br /> ........... ................9... . . . . :�.................. <br /> Zonin Admini trator .-J 8 8 8 8 $ 8 c) <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 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 marle without approval of the Zoning Aclm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />