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Burnett County Office of Zoning Administrator e n --I 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N <br /> shown'herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use A <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a ;5 <br /> . WRQ 4�t..(.. ......... ..............................5 .!^ .. ....................................... <br /> OW — <br /> a o <br /> f <br /> R0(please..print){....... ..................... CONTRACTOR or SURVEYOR or AGENT <br /> ^ � <br /> m <br /> 11.15-..3.. ..X .. ..RESS <br /> .... ........................... ......1.................................................................... . <br /> ADDRES� ADDRESS m <br /> ADDRESSADDRESS34.�..-..S-6.... .v........................... ............................................................................................ <br /> PHONE <br /> PHONE .......................................... ................................................... / <br /> .........................S.f41 .C. <br /> . <br /> PLUMBER WELL DRILLER <br /> ff "Q1, <br /> ................................ ......................................................... ...A......................................................................................... ;�} 0 <br /> ADDRESS ft DDRESS Ir .o LA <br /> 0........................................................................................... . ..................................................................................... .: <br /> PHONE PHON...... E Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ...�... . o <br /> New Building „X,� Type Construction: No. Bedrooms <br /> Addition ., .,,_ „�,V1-, „ , ,,. ... .. Septic Tank Size Gals. <br /> .......... <br /> y Z.... .......... .. <br /> Sanitary „X„�(,� Size .Z.. ft. x .r7........... ft. <br /> t If <br /> 4a. Absorption Field Site: <br /> Filling/Grading .......... Height.. .. $tor as ... ........... <br /> Moving ...... Area ......... ..Et... ...... . . . ..... Soil Type .................................... <br /> rj <br /> MobileHome $IOPe ...... ................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well home,home,garage, motel, etc.) Dry Well .......... f E <br /> Subdivision Seepage Trench .......... <br /> �l� .�,t..�.Y.................. { <br /> CampingUnit. . . . �n Privy <br /> .......... .............�.l1..G..TO�: ............ Seepage Bed .......... <br /> ______________________________________________________________________ O .N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> Q <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 (y H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> u i ' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: R <br /> Iiiii..... ft. x.31.... ft. — , 0tai,�......... sq.ft. ............................................................................... <br /> In: N <br /> S � 2 ft % iaFGlnGc6 <br /> N O <br /> D ° <br /> 12 IA <br /> 0 <br /> ± D <br /> erm l�- <br /> F? m Q <br /> Z <br /> O <br /> d <br /> m <br /> ]7 (n r v rn m Z <br /> n Q < c m <br /> F <br /> A N< — m <br /> Z O o m D n m <br /> o a � 70 <br /> n 4111 — $ <br /> 7— � �(� p <br /> R_ .... ... ................ ........... ...-................... o <br /> Si n ure of O.wner A e t ....... ^ Date <br /> X M <br /> Remarks ............................. <br /> In m <br /> M p <br /> e» <br /> n <br /> ........................................................................................................... . ..... ............ <br /> o wNv, <br /> T <br /> Inspection Date ....................................... ................ <br /> Z In.g Xdim. instrator <br /> 8 8 8 8 <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 />