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Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> •4 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < — 00 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. na <br /> N.O.9L.�........42, 5A14 S 7-xq ,0................... s t c f = d o <br /> ............. ................... .............T-0-R...........................AGENT,OWNER (please print) CONTRACTOR or,SURVEYOR or AGENT m � <br /> .T.....l.......... <br /> ?'rxc....a.�.��...................................... ......... <br /> ADDRESSiu <br /> ADDRESS <br /> fyE�l� Stell ll 5-4/$9 3 <br /> .. ............................................................ <br /> ADDRESS . .......................................................................................... <br /> ADDRESS <br /> PHONEHO <br /> —N-E................................................................................. <br /> PHONE <br /> PLUMBER .WEL....... <br /> L..D..RLL. I'LL..ER...................................................................... <br /> ........................................................................................... . .......................................................................................... <br /> ADDRESS ADDRESS <br /> n O <br /> PHONE PHONE N <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building k, Type of Construction: No. Bedrooms .......... <br /> Addition ,,, . ., „+-gip,d..... Septic Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ......1...4.. ft. x ......�.�0... ft. .......... <br /> Filling/Grading ,.,,,,.,,, Height l2..' Stories ....I......... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .-................................. '• ! r i <br /> Mobile HomeSlo e <br /> .......................................... <br /> .......... P : .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well ...... ... home,garage, motel, etc.) Dry Weil .......... <br /> Subdivision Seepage Trench .......... <br /> Camping Unit ..... .... .................................................... Privy <br /> .................................................... Seepage Bed <br /> __-----_---------------------------------------------------------- <br /> Location <br /> -------------------------------Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched In Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If prnperty is located at a highway inter o- <br /> section, show the intersectirg highways and the setbacks required along them and at the intersection- CLEARLY LABFL EXISTING = <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> -------------------- -- --------------------------------------------------_ i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — '/K�.�...0 L '7��a..... sq. ft. ............................................................................... <br /> m <br /> n <br /> — ----I <br /> N <br /> O 7 <br /> czar n <br /> ,N )J <br /> E/Y:- -7 Z <br /> O <br /> d <br /> h <br /> m <br /> 7J fnr � � m so <br /> m <br /> a' <br /> on d C ` c <br /> „ - am <br /> Z cd o' n 70 <br /> o <br /> Fn 1 <br /> 0 <br /> Is <br /> .......................................... .. ..........................$�.... _ A <br /> Signature of Owner or A nt ate <br /> 0 <br /> �/c � . ..... ...... ... ...... .�.�., ...... X <br /> Remarks ..�..(/......... .... ........ ... . iG�. <br /> � : m <br /> o <br /> .................................................................................................................................................................................. <br /> u <br /> Inspection Date ....................................... - U H <br /> //� (,/�p� N N (O N m <br /> 1 .. .... . .. :...... N00000m <br /> Zoning Admi strator K✓ : : $ 0 0 0 0 0 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 wild <br /> - <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 /> SEWERSYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />