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(i') (�O))(/ ), <br /> Buinett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITIs 3 <br /> ~ S <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ,p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ^,p <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> re ulations of the State of Wisconsin ,p c^ a Y= . <br /> .:......iP.f�t;la' f G �'f JAY it is <br /> OWNER (please print) CONTRACTOR o SURVEYOR r AGENT <br /> CDZs <br /> ....................... ✓ .....5 . a �.. ................... ................ <br /> 3:!j: % +�9 t` <br /> ADDRESS ADDRESS v4k) of <br /> < E t F <br /> ....`..r......`....................}...........:.............1:i...rv......:...a........ .. .. ........... 00, <br /> ... <br /> ADDRESS ADDRESS <br /> .. . . <br /> 4� ) 4. ._.� .. <br /> PHONE PHONE, - i <br /> r` <br /> .V `J. ...L..:..r...:.:......... ................. ........ ...................................... �?.................`'�.....: . ...... ......... <br /> ER WELL WELL DRILLER <br /> .... ................................ <br /> ...:.... ............................................................ i <br /> ADDRESS ADDRESS <br /> n, G <br /> ?/..5".-.....�1. ..41.-...Ir.f. t............................ . .......................................................................................... N <br /> PHONE PHONE Z = <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: P c » <br /> 1. Work: No. Bathrooms ..,�.... N 0 ,•,' <br /> 2. New Building Details <br /> NBuilding ✓ Type of Construction: No. Bedrooms <br /> .......... ..c :... ?W <br /> ew <br /> CD <br /> Addition „(�. .......0. ,F;,,r,l;, Septic Tank Size Gals. .......... <br /> Sanitary ..✓..... Size .... ft. x .. ft. ...I...... a , <br /> ( Q <br /> Filling/Grading .......... Heigh StoneS..'. tion Field Site: <br /> Moving <br /> ........ 4a. Absorption .o ;G V <br /> Movinq . ........ Area ` Soil Type .................................... r <br /> Mobile Home .......... Slope .......................................... ? ^' iC <br /> Privy .......... 3. Use (describe exactly,-1 -family <br /> Perc. Rate ................................... ^� <br /> Wellv Dry Well ........:... home,garage, motel,etc.) . ao X <br /> Seepage Trench .......... <br /> Subdivision ..... ....... , ..41.'-.,a. Privy i <br /> __�mpinq Unit_________________` 1. ._. -- `-•-'.�-.._Gx1lKL _ Seepage Bed __________ " :� •Y \. <br /> C� N i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. ,1`' „57r <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS :O 0 <br /> 5 t Size: +� p-��T� J�'° �"f� �. Fig. A. 6 � tion: ''// .� h �� :� <br /> to 1.... <br /> ft. ::. .." � .. C.G. ....y.C� .• _ Of1�4�Ub7 :� i <br /> .......... sq.ft. //// <br /> 1p0,07 <br /> d <br /> � N <br /> C <br /> Cad M� <br /> (31<1 � - �._. <br /> m <br /> OZ C� <br /> w <br /> 6� <br /> m r n c <br /> Lt7� ° �N a-W-111 <br /> ' m <br /> _ r 4We4b 1b bf A7-1 � so ° <br /> }-- _ . Via : y <br /> S�a'Pi �61 Oo 0 o ' M <br /> a <br /> t:K ......... ...... � . ../�/�F x o . v <br /> I ature of Own rfgent DateRemarks .......JJ : . . ' '"' ............. ............ .....................( N . <br /> ....:�� ....6...�.. ............................................................ ....................................... o <br /> Inspection Date .......5�/V. .V..!........ ... .. .... .... .... .. .. ... ....... ........ fT tT N O O (n m <br /> Zoning Admini or S g $ g g g (h <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a Septic tank,do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />