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Burnett County Office of Zoning Administrator � � o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 1 <br /> h <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 70 :e <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. CD <br /> a O~r <br /> CL <br /> —AV4P' r1`L.o.....r4.•. . sJ.t .N.$dAl..................... ......... ....................... <br /> ...�R 0�' ..�.1.�.4.S.A.....R.F.. � °C <br /> /./y�� C G <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT cc m <br /> 3.p7 P . MAR 0 4 <br /> ,r .r� ........ .V.� .... . •.. <br /> :................. 46A ..l i���.Ae:s.•o�7.............................. <br /> ADDRESS , <br /> m <br /> . 4.8.t31./V. .D./►. .�E........MJ.A1&.................... .......: ....�..... a!k .3 �Pt4, 7"g�$41�k,� <br /> ADDRESS ADDRESS ...... ....... <br /> ....................................................... .....4.f. f..7.......................................................... <br /> PHONE PHONE <br /> .. ............................................................................................ <br /> PLUMBER WELL DRILLER .� <br /> p <br /> ADDRESS ADDRESS CD <br /> c* < <br /> ............ 0 O <br /> PHONE PHONE � <br /> DESCRIPTION o <br /> 4. Sanitary Facilities: o ° <br /> 1. Work: 2. New Building Details No. Bathrooms -0 <br /> New Building No. Bedrooms ......... °a <br /> .......... Type of Construction: <br /> CD <br /> Addition ...... „• ••„•........... Septic Tank Size Gals. <br /> SanitarySize .../1....... ft. x Y <br /> /... ft...... . . . . : <br /> Filling .......... Height............. Stories ...�.......... 4a. Absorption Field Site: <br /> Moving Area Soil Type ...SA MA.................... r— <br /> . <br /> o <br /> Grading .......... Slope .......................................... .+ <br /> Mobile Home ........•. 3. Use (describe exactly, 1 -family Perc. Rate ../.r;j ....................... <br /> Privy home,garage, motel, etc.) Dry Well y'"., <br /> Well Seepage Trench /.......... <br /> .......... <br /> Subdivision �� S�G���1/+� Privy <br /> .......... <br /> Seepage Bed .......•. <br /> -------------------------------------------------- --------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road �� c <br /> 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- L _Q <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 1 O <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: — <br /> )'r... ft. x . .O..d... ft. — ............................... sq.ft. ....**/Ow1-- <br /> ?-ou�,�( •�' waso R'r'VFA <br /> CD <br /> w <br /> �X(s 71/Y6� j� c� a gin/ o <br /> ADO 14 <br /> ppRo , <br /> ON <br /> z <br /> J o <br /> m <br /> CCD C cri CD d C CD <br /> CD Naas = Q <br /> -0 U7<.C <br /> z o N. ; < g m <br /> o <br /> N4f = 3 <br /> o � <br /> o <br /> N)CD <br /> V' <br /> ,.... .. .... .. ............... o E <br /> m <br /> p <br /> Signature of wner or Agent Date C <br /> Remarks m ; ; m <br /> .......................................................................................................... C <br /> Gq <br /> ..... ............................................................................................................................................................................. <br /> .............. <br /> : . . . . . <br /> Inspection Date : o 0 0 0 0 C'A m <br /> p .. ...... .....g.......... .......... ............... 000000m <br /> Zonin Administrator o 0 0 0 0 o y <br /> TOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ig 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 />