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C, <br /> Burnett (I,hty Office of Zoning Administrator W 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 1 m µ <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 <br /> "and the laws and regulattt,otns of the State of Wisconsin. o- <br /> ..`.:..!..'!'[%Y.. ..... .... ..... .. . ... ... ............... ........Y.!........ .. ...... ............ .W.. ` O?.`�:............ O�. <br /> OWNER (please print) CONTRACT Roir SURVEVO or AGENT a <br /> �. <br /> ........................................................................................... .......... .. .......... . .... �-- ..zo.f d � <br /> ADDRESS ADDRES <br /> ... .. ... . ........7 <br /> ADDR 5 ADDRESS <br /> . . .....-.. .y..�. ....-.s.-o..s.-.. y .... ..... ................................. ................................ y <br /> PHONEPHONE <br /> ............................................................. i <br /> PLUMBER WELL DRILLER r� <br /> 7 <br /> .. . .............................................................................. .................................................................................. <br /> �.......... � ' <br /> ......... . <br /> ADDRESS ADDRESS : <br /> o <br /> ........... <br /> ........................................................................................... .PHO'H"O"'.NE............................................. .......................... o <br /> PHONE ZH r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details "•'•••••• o <br /> New Building •......... Type of C n ru ion: No. Bedrooms .......... i 'U <br /> Addition ...v ..,....,�?^................. <br /> Septic Tank Size Gals. .......... <br /> .N................ . <br /> Sanitary .......... Size ......y.... ft. x .....o3...y ft. .......... <br /> Filling/Grading .....•.... Height........... Stories ..l........... 4a. Absorption Field Site: <br /> Moving .......... Area .... ..:....... Soil Type .................................... .o <br /> Mobile Home .......... Slope .......................................... <br /> Y, Y Pere. Rate ................................... i <br /> Privy <br /> .......... 3. Use (describeexactly, 1 -family <br /> Dry Well <br /> hope, <br /> g.o.r.a. <br /> e, ptel, eta) <br /> Seepage Trench ..........ion .......... . <br /> Camping Unit .......... Priv .......... <br /> .. . . .. .................... Seepage Bed .......... <br /> ---------------------------------------------------------------------- <br /> / . <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 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 _ °- <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 /> ___ ___ <br /> 5. Lot Size: Fig. A. 6. Loco�?Dn: / G'--- .. <br /> ................ ft. x .............. ft. — . ..................... sq. <br /> ft. / �..... .1 ...-.............................. .. .. Uz"�•, E t <br /> N O <br /> O � <br /> E <br /> C] <br /> 0 <br /> O <br /> O <br /> S <br /> z <br /> o <br /> d <br /> m <br /> Gf <br /> 7] n r v Z <br /> n ccr < c m <br /> 0 ro m <br /> m : m <br /> Z oo. . n 70 <br /> o uy' . <br /> W P <br /> ..... ........... . ........................ ............. ..... yl5r � O C <br /> ena�- of Ow er or Ag t Date <br /> Remarks .:7...1..1.Q�`.!....(. ..`? 1......1 ..1...`.:.....rn.!fCf.. i"�G � ....Qn/./l O�Ci<n ...TP'^:F..,................... X m <br /> .., Pam.... r .r...... �� %..4�P.. ...... �h ......��-.....................................:. e <br /> ............................................................................................................. ........ <br /> .. <br /> n . . . . . . T <br /> m.. <br /> InspectionDate ....................................... .. ...... ....: ....... ... ............................. o r„ o u, o m <br /> Zoning remistrator $ $ $ $ $ S 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 />