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o".vi c11v-i1-T, <br /> Burnett County Office of Zoning Administrator E - o //o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3' o O <br /> TO THE ZON.I�4 ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < ; :O� <br /> shown *rein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use -a Mm e ;4q <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 cL <br /> ILYt'AlAll Al <br /> CD <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> CD <br /> ADy,RESS ADDRESS <br /> /��.S.. �r/r .......5�``...... .e. ............................................................................................ <br /> AQDRES5 ADDRESS <br /> 0.9............................................... ............................................................................... <br /> PHONE <br /> ..E <br /> PHONE E <br /> .W... .....D.. ............................................................................ : "V <br /> PLUMBER �,� ELL.. R..IL', <br /> v <br /> ADDRESS ,� ADDRESS <br /> n o <br /> < <br /> o <br /> . <br /> . .. .. ..... .. : <br /> PHONE PH..ONE. z :3 <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms :° <br /> 2. New Building Details 0 <br /> 9 <br /> No. Bedrooms °a <br /> New Building ..,... Type of Construction: <br /> Addition , ;1GN..,... DCf .,•,.,. Septic Tank Size Gals. `• <br /> ... < <br /> Sanitary .......... Size ...../;94.. ft. x ..../,;.U.. ft. ......••• <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area .......... Soil Type .................................... r- <br /> Grading Slope .......................................... <br /> o <br /> Mobile Home ..••.... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, e c.) Dry Well .......... <br /> Well .......... .1`!. &'f�l.�Q. G N... Seepage Trench c <br /> Q .. .. <br /> Subdivision .......... .................................................... Privy <br /> Seepage Bed .......... i :o :4A <br /> ---------------------------------------------------------------------- (4 N <br /> 1 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road �� a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <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. y <br /> o' <br /> ------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Loc tion:. <br /> `fQ�...... ft. x .j03. .. ft — ............................... sq.ft. ..4r. NIE...� ....... <br /> ........................... ; <br /> �{3�7 �w , ss TowNsN,P <br /> �� y �cFC /_'9K'f. <br /> N O' <br /> ©0 — O <br /> IdANC, <br /> �. <br /> aZz <br /> f i a <br /> t Q� v ) dCD <br /> I i _ <br /> j CD CD <br /> T Naas — + � <br /> I •6 cn <' <br /> � Z cZ;� : c * m <br /> J <br /> o � � <br /> .................. ....... . ? m <br /> p <br /> Sigraure;of r Agent Date <br /> X 70 <br /> Rerks ................................................................... -n v <br /> .................................................................................................:.... . <br /> ♦ � <br /> .... . LI�.. ......./ ?........ -♦e........ G/.. ............. ,- 0/\_ s9 <br /> ... ............ ... .... ............................................................ <br /> T <br /> Inspection Date o 0 0 0 o cNr, m <br /> . . ....... . . . <br /> Zoning Administr r 00 0 0 0 o rn <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 must 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 made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />