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ON COMPUTER/SCANNED <br /> Burnett County Office of Zoning Administ{ator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o alt <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and looted as H7 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lad Use m C <br /> Ordinance, Sanitation Code, <br /> and <br /> ,{with <br /> haall <br /> �other applicable County Ordinances and the <br /> ellaws and regulations of the State of Wis onsin. 3 ou t�• <br /> OWNER PI> Printll l`JI !.lhJ.!..`.!.............................. C.. !.! 'A...s !_7.... — n :......................... h m i-�c- <br /> R or SURVEYOR or AGENT a <br /> :•d!?{Q...S �Ox 1. .. ............. ...... - <br /> ADDRESS AD R S .�............................ ... ... <br /> a , :� <br /> ............................................................................ ....ADDRE....RESS ......... .r................................................. ......... 7 <br /> ADDRESS <br /> ........................................................................................... .......................................................................... <br /> PHONE ........ ......... <br /> PHONE <br /> ........................................................................................... WE"E"L..L...DR...I......LLER............................................................. ......... <br /> PLUMBER <br /> ADDRESS ADDRESS m Ll <br /> n o <br /> ....... ......... <br /> ........................................................................................... ....PHO....................................................................... <br /> PHONE NE Z � � <br /> DESCRIPTION 4. Sanitary Facilities: P o 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ".."' o ' <br /> New Building „ ,,,,,,,, Type of Construction: No. Bedrooms .......... ' <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary ....... Size ft. x ft. ..... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingSoil Type .................................... r <br /> .......... Area ........................................... <br /> 0 <br /> Mobile Home Slope .......................................... <br /> Privy .. ....... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well Dry Well `` ,, <br /> ,,, ,,,, home,garage, motel, etc.) ”"""" .JJ <br /> Subdivision Seepage Trench .......... <br /> --Camping Unit Privy .......... ' <br /> Seepage Bed ......... <br /> -------------------------------------------------------- --- vi- c✓ I <br /> Location of proposed structures and existing structures, well, sewage systems, roads, eta, should be sketched in Fig, A. Inclu le road <br /> or <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 STHU — RES AND ADDITIONS. o <br /> 5. Lot Size: Fig, A. 6. Location: - <br /> ................ ft. x .............. ft. — ............................... sq. ft. ............................................................................... <br /> T. <br /> N <br /> Pan liS <br /> l o <br /> c_l j l a " a <br /> N <br /> Z <br /> L5) <br /> a< < ro <br /> per <br /> Z oo' a <br /> 70 <br /> o aro <br /> 3 <br /> �o m <br /> i <br /> �. .. f ` <br /> Signature of Owner or Agent Date — <br /> X 7J <br /> Remarks ................................................................................................................................................................. ....... m m <br /> m <br /> � n <br /> .......................................................................................................................................................................... <br /> Inspection Date .. ...... ..... ....... .... m <br /> Zoning Administrator, �/A ��. 8 0 0 8 8 S y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures iivolving 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 be issued. Do not purchase or install a septic tank, do any pl tr ing or start any build <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyer) here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />