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Burnett County Office of Zoning Administrator 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and looted as < u, -^ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County La d Use - <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin a <br /> 3 <br /> -a <br /> ..... ... . .......... .........ruce.....�5..Th1a�.................... arCft.... � O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT o. <br /> ............................. AD. R. Dner... (r..�lP .i.n.. ....................... a �4 <br /> ADDRESS SSS S � I <br /> .....M............................................................ <br /> ADDRESS ADDRESS <br /> W. lr , ... 3............. <br /> PHONE <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER ?f n <br /> l/ 1 <br /> ADDRESS ADDRESS n o -� <br /> ........................................................................................... . . . . ....................................................................... .......... o .. <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details '••"•' o <br /> New Building No. Bedrooms ....... <br /> ...,,...., Type of Construction: z <br /> m . <br /> AdditionSeptic Tank Size Gals. .......... � <br /> ....... ................. ....................... .. <br /> Sanitary „......•. Size ft. x ft. """"" ' <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... <br /> Mobile Home .......... Slope ............................... .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ........................ .......... <br /> Well home,garage, motel, etc.) Dry Well .......... <br /> Subdivision Seepage Trench .......... <br /> CampingUnit .......... ............................I....................... <br /> Seepage Bed .......... <br /> -- N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched in Fig. A. Inclu e road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highw y Inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EX STING <br /> a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ................................................................... ........... <br /> i; <br /> LLc�iC�1PGG� J� <br /> N O <br /> Pa es Il -I�� se <br /> o <br /> — 0 <br /> � m <br /> Z <br /> _ O <br /> d <br /> 7 <br /> JJ r a 0m Z <br /> n ` Z M n_ <br /> c m <br /> N ,� - af <br /> Ic 01 <br /> Darn <br /> .101 <br /> Wa <br /> D rr <br /> -aq- rxs <br /> Signature of Owner or Agent Date :-\o C <br /> X z <br /> Remarks ......................................................................................................................................................................... rr <br /> e» <br /> ....................................................................................................................................... ..................... ..... <br /> .. ..... <br /> InspectionDate ....................................... ...... ........... . . . 9... .... ..... .. . . :C) rr <br /> �Zonin Administra r 8 8 8 8 8 8 u. <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 percolatio i test must be attached to <br /> this application before a permit will tie issued. Do not purchase or install a septic tank, do any pl Ymbing 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 he Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />