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Burnett Cponty Office of Zoning Administrator iv (01 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as v 0 <br /> N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use I eI CD <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- W <br /> ie Brownewell Rick Engstrom- Harle — <br /> . B <br /> ............................. ........................5................................................................. to 0 <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a _ ::E: D CC <br /> 4307 Santa Fe Court Siren, WI Q Cn <br /> Ao�R'Ess Indianapolis........Ind. ADDRESS <br /> C <br /> :N• <br /> ..A......R........................... FJ- <br /> ......................................................... <br /> ADDRESS DD ESS <br /> ............. ............. . <br /> PHONE PHONE :� <br /> Don Daniels Don Daniels...................................................... :bd <br /> PLUMBER WELL DRILLER :E <br /> Sirena...WI...... 48 2 <br /> 7.......................................... ............................................................................................ o <br /> ADDRESS ADDRESS <br /> CD <br /> 0 :(D <br /> .............................. Ll! 0 :N <br /> PHONE PHONE Z :3r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Budding Details •�...... i o <br /> New Building ...X.., Type f Construction: No. Bedrooms .2...... CD <br /> Addition kA <br /> game Septic Tank Size Gals. <br /> .... ........................... 754... 0 <br /> Sanitary ...X.... Size ......3.8... ft. x ....�(?.... ft. .......... !D :�! W <br /> Filling .......... Height............. Stories .....I........ <br /> 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... T ly r <br /> ........ . ........................................... <br /> o <br /> Grading Slope .......................................... p, � : <br /> .......... . <br /> Perc. Rate ................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family "5 <br /> Dr Well <br /> Privy •......... home,garage, motel, etc.) y fi) <br /> Well X Seepage Trench .......... 5 <br /> .......... <br /> .....&i—n$.le,...f-,ml.l.�r....home ) � <br /> Subdivision „•,,, Privy .... ..... <br /> R <br /> Seepage Bed --x...... <br /> ----------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 0- <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. O H <br /> tfV o. <br /> 5. Lot Size:--- ----------------------Fig. A. 6. Location------------------------ N � <br /> 2�2,2 acres <br /> ................ t. x ft. <br /> G C <br /> G CD <br /> o o. <br /> �1 <br /> 0 <br /> 7 <br /> ?Ij <br /> OLM <br /> r i (D <br /> 70 cn Cl)coZ <br /> CD c m <br /> < mCD <br /> W• NaQ•G <br /> -o cn< C, d 5' b <br /> U3 M <br /> Z O p S <br /> m m <br /> 01 `n <br /> CD M <br /> o � <br /> .. C <br /> Signature of Owner or Agent Date <br /> ��11 �aQa x <br /> Remarks .J..Lte. m <br /> - <br /> CD <br /> ................................................................................................................ . ................ ....... . ...................................... :II <br /> N T <br /> Inspection Date ....................................... oni ............ ................................ 4: <br /> 000 ocnIT7 <br /> Zoning Ad istrator °: o 0 0 �o o Cn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> oefore 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 /> ✓vith 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 />