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Burnett County Office of Zoning Administrator <br /> ----At <br /> o <br /> ;%PPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> 0 <br /> 00 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Iota ed as c <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County La Use m , <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisc nsn. 3 a <br /> - _ <br /> / !..' .r.! . -...................!.l.�.. e..,........................ . ................5............................................................ ........ <br /> a :( p <br /> ON (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ' ..o.....Wl�.l .�. ......5. a <br /> ........... ADDRESS m <br /> ADDRESS �--. <br /> �!J..4..1...C..s ... .n..........S.SU.. .r�......................................................................... .. :U1 <br /> .......... ........ <br /> � <br /> ADD ESS ADDRESS '('jQ <br /> }.. ... <br /> .. ...... ................ ............................................................... . ................................................................................ ......... <br /> PHONE PHONE <br /> r^K <br /> .vi........... . ................................................................................ ......... { <br /> . . ...................................................................... WELL DRILLER i� <br /> PLUMBER <br /> .. .......................................................................... ......... m LD <br /> ADDRESS <br /> ADDRESS � o : <br /> .. .......... . . . ........................................................ . ................................................................................ ......... <br /> .... ..... .. ........ o <br /> PHONE PHONE o �^ n <br /> DESCRIPTION 4. Sanitary Facilities: ' ' <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms ......... : o i 1 <br /> New Building ...: ... Type of Construction: No. Bedrooms ..� i� <br /> Addition ,� t`Q.T,y�,r...'....... ...... Septic Tank Size Gals. <br /> .......... <br /> Sanitary ...]1.... Size ...... a:... ft. x ....a.. ... ft. i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingArea .............................. .......... Soil Type ............. . ...... .......... o r <br /> Slope ............................... .......... <br /> Mobile Home .......... a. <br /> Privy .......... 3. Use (describe exact) -family <br /> Perc. Rate ........................ .......... ' <br /> Well home,garage, motel, et Dry Well .••• A r <br /> "' "" Seepage Trench .......... :T <br /> Subdivision .......... .................................................... Privy ;C <br /> CampingUnit .......... .................................................... Seepage Bed .......... ...... f <br /> Locahon of proposed structures and existing structures, well, sewage systems, roads, eta_, should be sketched in Fig A_ Inclu e road ,. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highwi y inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EX STING : r c; i <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> rt t 7 orf <br /> ------------------------ - <br /> 5. Lot Size: / 4 rN7 Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ...(r1.:�................. sq.ft. ................................................................... ........... <br /> lJ� <br /> n <br /> t N O <br /> � V <br /> :70; a <br /> d <br /> 2,x a 1 <br /> fs� <br /> / e Nr v .NmZ <br /> oN: ° Dai <br /> Z o on <br /> o _D nro ; <br /> A <br /> i o � <br /> �G; ......�s /W................................... o <br /> Signature of 0 er or Agent Date X <br /> TI r <br /> Remarks ... ....�1... x. c�'`Gc`.f:7.f�...:..................................................................................................................... . . : : . ; f <br /> ............................................................................................................................................................................. .......... <br /> oe <br /> ...................................................'.................................................... .................................. ....... <br /> {u\ <br /> Inspection Date ..:5��.u.......�.� I ....�.'fu<< . . .!. .. ... ...... � � o `r o <br /> ........... ............ ing <br /> Zoning Admi rator <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 percolate n test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any I umbing Or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the nformat}on conveyed here <br /> with is found to exist. Changes In plans or specifications shall not be made without approval o the Zoning Adm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFIC AND APPROVED. <br />