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za�77 oe)�Y. <br /> Burnett County Office of Zoning Administrator lip ;F o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the .J- . <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> reg u tions oftheStat/�of Wiscons - $ n <br /> (..:.1.. ..4� 4... . ....... .:h 'e.................... ........................................................................ n y Q <br /> . . iY 3 <br /> OWNER (P esas print) CONTRACTOR or SURVEYOR or AGENT T� <br /> f.. . .`1.........Q .�.Y.e�w:�.K.. ..........Sr................ ................ <br /> ............................................................................ C <br /> AD SS ADDRESS <br /> �......P.�4:.�.....�.I............................ ....... . .......................................................................................... QW <br /> AD RESS ADDRESS <br /> S�- a a <br /> 1. ..-...!f.. ........................9................................ ............................................................................................ n <br /> PH(�.l€ .................................................................... PHONE <br /> PLUMB ........ . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS............................................................................ .ADDRESS............................................................................ n G <br /> .....................r.. .. .................................................. <br /> PHONE PHONE 2r-1 !� <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> v <br /> 1. Work: 2. New Buildin Details No. Bathrooms .......... -* o <br /> 9 <br /> New Building „ ,.,,.,.. Type of Constructifood, No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary ...rr..... Size .............. ft. x .............. ft. <br /> 7..T.. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r <br /> o <br /> Mobile HomeSlope .......................................... .. <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... 0 <br /> Dry Well .......... <br /> Well ,......... home,garage,motel, etc.) Seepage Trench o <br /> Subdivision ”"' "" ' <br /> .......... .................................................. <br /> --Camping Unit- Privy qv :P1.......... .................................................... <br /> Seepage Bed �.� .. <br /> ------------------------------------------------------------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :� c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at �1 ,` <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 ;r^ <br /> -------------------------------------------------------------- - 1 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq.ft. ............................................................................... <br /> A � <br /> �l1 <br /> N N:w\ O <br /> T <br /> N � <br /> /TTv O <br /> ]� v S <br /> / Z <br /> O <br /> D <br /> N <br /> J <br /> b <br /> N (D 7) N r O C3 0 <br /> p - - m <br /> M <br /> C O< : d C y J J 3 <br /> O <br /> Z <br /> O .0 D ' � <br /> Nd <br /> 20 m <br /> C C <br /> n m <br /> l <br /> ................................................ ................................e ofUner or Agent Date $ <br /> marks ..........:.1'.., a... v7i ` `'.. .... :........................................... n <br /> I. ......................... .. <br /> vCkfJ.. �i !. .............. ... Xis.(NG�.. 10ti� �...l.:.C(n�,. .. � . `�. .. <br /> ................... <br /> 8 <br /> .....................�...................................................................... l ,Jn{ <br /> g <br /> T <br /> �ion Date .... -� ..... m <br /> ... .......... og Zonin9Administra <br /> $ fn <br /> 'E: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> regin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> wed. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> ,.ped if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />