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C411 P <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d <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 <br /> Burnett County Land Use Ordinance, Sanitatjon Cope, and with all other applicable County Ordinances and the laws and <br /> regu Itons9the State <br /> �r.....7 .. St�..e,f.o:�.f cWisconsin. <br /> ., <br /> > �GENT <br /> ........ a3d• <br /> a- <br /> : t <br /> •..� <br /> ....... n ........ Y ... ......... ....... ............ <br /> OIse print) CONTRACTOR or RVEYORO A <br /> ................ ................�-✓�................................................ <br /> ADDRESSADDRESS................................................... . ............................................................................ <br /> ADDRESSADDRESS <br /> i <br /> ......................................................::.. <br /> ......:.......................... ............................................................................................ <br /> PHO PHONE <br /> (i 46 <br /> U.j....................... . <br /> KU WELL DRILLER 'moo ? I <br /> O i! <br /> ADDRESS ADDRESS � o <br /> .......................................................... <br /> .....ON....E........................................ <br /> ............................... <br /> ........ <br /> .... O <br /> PHONE PH <br /> DESCRIPTION 4. Sanitary Facilities: / ° o ° al <br /> 1. Work: No. Bathrooms ! i° <br /> 2. New Building Details <br /> New Building Type oLConstruction: No. Bedrooms ....1... '>3 R <br /> Addition f ^0lk'L–t Septic Tank Size Gals. .......... i— <br /> SaniterySf <br /> • •• Size ..../ Stories.. ft. x .`..lj... ... ft. <br /> Filling/Grading Height,l.�l�r. <br /> • • • -�– �� <br /> •/N. – 4a. Absorption Field Site: <br /> ... ......1L�...... ' <br /> Moving .y�.�.. Soil Type .................................... : -r i <br /> .......... Area ......... ........... <br /> Mobile Home Slope <br /> Privy .....•.••, 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... <br /> Well ........., home, arage,motet,. tc.) Dry Well ........., z <br /> Subdivision .......... l...I!f�. %/ L"ett•q� Seepage Trench .......... <br /> Camping Unit Privy .......... .�] <br /> ......... ............................................. . .... ✓Y� <br /> Seepage Bed <br /> ---------------------------------------------------------------------- rn <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 �� F <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. L� o <br /> ---------------------------------------------------------------------- i <br /> 5. Lot S e:� n ... Fig. A. 6. Location: <br /> ft. x ....... .... ft. – / .... sq.ft. ............................................................................... <br /> .. .........i.... ............ <br /> / N NA O <br /> 7Y <br /> d <br /> M <br /> D In W 0 0 W . <br /> A NCr = Dnany <br /> 3 z,_o ° a10 <br /> =i <br /> a <br /> 2 - m <br /> S6.r.0 ,�x m <br /> �� -................�7 <br /> Signature of.O�w`n^er or geep,„ p r� ,pDate' I,,I �,�,,V.W. <br /> /� <br /> Remarks ...+ ..... .hM!.!.1.T.:�..� Q�.../......�.!,.....Iv.ftj....�?(�!.,. .. ..S..t1-.'.ZI71.i.. ..... <br /> r <br /> 'J .. <br /> ...... -4....... ... ...LtIQi.1.7...4.i.(.1�..... .... ...../�-f.�.. . .. <br /> ........................................................................................................... ....... ................. ........................ <br /> Inspection Date �� o o <br /> ...................................... .......... .................................... <br /> Zoning �ministrator o $ g $ <br /> NOTE: A preliminary site inspection must be made and site 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 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 />