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Burnett County Office of Zoning Administrator 3 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT Is <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ., <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n 91 <br /> E <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the Stale of Wisconsin. <br /> w - d <br /> ..per.,....... .................1f�1S..........fl� k«s.............. <br /> ... _ <br /> OWNER 1PIesseprintl CONTRACTOR or SURVEYOR or AGE 7(1••/• 7 <br /> 13753....... .... e.4 ... ..................... . ...........L ......W..,�._...........5 <br /> A <br /> 1.... . <br /> ADDRESS <br /> Cj .�5�".W.. ....1..f .........�47.I1.......... .ADDRESS............................................................................ <br /> ADDRESS <br /> ............. ...........XG.-.4/M... <br /> PHONE PHONE <br /> .................................................. <br /> ........................................................................................... .E. ......RILL........ER..................... <br /> PLUMBER WLL D <br /> O <br /> ADDRESS ADDRESS0 a <br /> .............. <br /> ........................................................................................... .P.H..ONE.............................................. ......................... :-: <br /> PHONE 0 0 <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ..........New BuildingNo. Bedrooms Type of Construction: """"" <br /> Septic Tank Size Gals. <br /> Addition .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... <br /> .......... Area ........................... ............. <br /> .. Slope .................................I........ <br /> MODIIe Home ....... .. <br /> Privy .. 3. Use (describe exactly,'1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... _ iQ <br /> Subdivision Seepage Trench Zo <br /> __Cam Ping Unit Privy <br /> .......... <br /> .......... .................................................... Seepage Bed .......... i <br /> --------------------------- <br /> o t_________ ______ Plivy Seepage Bed ..........________________ (1, i <br /> 4]11(v T1'� <br /> I N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. '�. _ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. — M <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x{.az.�ft. . ............................... sq. ft. ............................................................................... 'a <br /> t � . <br /> o <br /> 21 <br /> 7 <br /> a � sa �o <br /> N y 0 m <br /> Zgo : ." o.22 <br /> a ' 1 <br /> u n 9 <br /> rn <br /> O <br /> c <br /> �_ �................................ . m <br /> gnature of Owner or Agent Date $ <br /> N <br /> Remarks m n <br /> .. ................................................................................................... ....... ................ ..................................................... <br /> o <br /> un Uri <br /> InspectionDate ....................................... ... . ...... . ......... ............................................ $ $ $ $ fmA <br /> Zoning Administrator <br /> NOTE: A preliminary site inspection must be made ands approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. 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 /> revoked it 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 />