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3urnett County Office of Zoning Administrator y o Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> -O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 90 L nV SCMW—D: <br /> )rdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. I C <br /> =7 / .................... ....4"'O. ..I... i1'rK.. y `D <br /> )WNER (please print) CONTRACTOR or SURVEYOR or AGENT co <br /> 57,�2 �! � <br /> a <br /> ............................................................................................ <br /> kDDRESS ADDRESS <br /> o . ..... ....:s.y ©..... f� , s7 ..�... ................................. <br /> ADDRESS ADDRESS �- <br /> �� ��. 7 .Z.............................................. �. <br /> 'HONE PHONE <br /> 'LUMBER WELL DRILLER <br /> \DDRESS ADDRESS r; G) <br /> h o :0 <br /> 'HONE................................................................................ PHONE................................................................................. :z <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: New Building Details No. Bathrooms ......... 71 i <br /> New Building Type of Construction: No. Bedrooms .......... 0 <br /> Addition J(,•„ U7x0 � Septic Tank Size Gals. <br /> ..... ....................... .. : <br /> Sanitary .......... Size ..X. ...... ft. x .......I..... ft. <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Typee .................................... <br /> .......... Area ........................................... Soil Ypy,. o <br /> Grading Slope ......................................... <br /> .......... w <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> Well O Seepage Trench .......... C <br /> ni ...�J..rt�•�1f' .. .... Privy ' <br /> Subdivision Y .......... L <br /> .................................................... Pj <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- U' <br /> cn <br /> -ocation of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road C <br /> atback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> action, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> N' <br /> TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. � o' <br /> ---------------------------------------------------------------------- <br /> J <br /> i. Lot Size: Fig. A. 6. Location: <br /> �,� ..3.. ft. x /PoW.. ft. sq.ft. .....otmo........................................................... <br /> --7- cn <br /> N 0� <br /> o <br /> vi <br /> kP1 <br /> Pry o Jegk <br /> CD a <br /> pvr�oCD <br /> cn <br /> ���co <br /> L � (G r�1.5y7�11/1i� mN �a a< A: a <br /> t JWYi •O cn< C� <br /> '( Q iN' N •G cn < M <br /> p <br /> i C.) "i <br /> 0 M <br /> /ar <br /> p <br /> to. ............ <br /> of Ow r ent ~ ° ` C <br /> X 70 <br /> -n : o............. .. ...................................................................................................................................................... � <br /> cfl <br /> ............................................................................................................ <br /> :0 <br /> ...... ,0. 0000 cTI n <br /> nspection Date ....................................... ... . .. ... . . . .... . 0 m <br /> Zonin9Adminis : <br /> 0 0 0 0 o W <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> !fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> is application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ith 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 />