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/J! I ('yY"t) <br /> .urnett County Office of Zoning Administrat r "f <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described aid � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of t e <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws aid 3 <br /> regulations of the State of Wisconsin. ^' m <br /> .P?,5..,f�f.faj' v........................... ..........�'/ e............................................................ .... <br /> OWNER (please print) / CONTRACTOR or SURVEYOR or AGENT <br /> s <br /> ADDRESS ADDRESS ; <br /> ........................................................................................... ....................................................................................... .... <br /> ADDRESS ADDRESS.................................................. ..... . . . <br /> PHONE PHONE <br /> i,tlQ.d.. ....�u. aio/m . ...................................................................... ..... <br /> . . <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS n o <br /> Q1 .4..-..��?P.�r................................................... ...................................................................................... ..... 0 <br /> PHONE PHONE Z r, r <br /> DESCRIPTION 4. Sanitary Facilities: ° c o <br /> 1. Work: 2. New Building Details No. Bathrooms 4 c <br /> New Building X Type of nstruction: No. Bedrooms .... ..... <br /> ""' Septic Tank Size Gals. .?. �}'1 ,Z <br /> Addition ..... .... ......... ..................... ....... . <br /> Sanitary .... ..... <br /> ..,d,.... Size ...aJ9.. ft. x ..3a....... ft. r i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type .................. <br /> Moving .......... Area ......................................... ............ ..... `: r <br /> o <br /> Mobile Home <br /> Slope ................+.� ^r <br /> .......... <br /> Perc. Rate ........1J.................. ..... m <br /> Privy ..... .... 3. Use (describe exactly, 1 -family <br /> home,gara Dry Well .... ..... _ <br /> yy�e motel,etc.) Z <br /> Subdivision / t(/ %/ Seepage Trench .......... o ? . <br /> ..... .... .................. . ......./..................... Privy <br /> B Z <br /> Campin Unit .......... .....................!*i ..................... i+ <br /> Seepage Bed ... , <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 locatE d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. `� `-, <br /> ----- ft. x .............. ft. --------- ----- <br /> . .. sq.ft. ----------------- — . .L p <br /> — Z <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I/ J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> . . . . ..y.:C.`� .....L.l. .l.y.ul................ <br /> / <br /> 0 <br /> IN <br /> O O <br /> T(1 J <br /> J <br /> f <br /> C/ � J <br /> 0 <br /> ZZ <br /> 0 <br /> a <br /> J <br /> M <br /> LD "a <br /> � O< co <br /> Z.-. D 1 <br /> � �o <br /> 20 m <br /> J . O <br /> C <br /> x A : m <br /> ................................................................... .. ...... o <br /> Signature of Owner or Agent Date $ <br /> d/rte.... ' :.. <br /> � m: <br /> Remarks . . .. ............ ......................:...::......... ...:.....-- ...:........:........'.......................... .... <br /> ........Y.�.�/... ... . . Hof•...../.a..�R✓.•...1L�/•( /..'. .. <br /> ............ ..........................................................................................?,a, <br /> .. .... .................. .. , <br /> Inspection Date .,y'....�.,t..:.. ............ ..t..:...Zoning AdministratoNOTE: A preliminary site inspection must be made and site appgranted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appi cation 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 beei 1 issued. A permit may be <br /> revoked 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 AP DROVED. <br />