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I <br /> Burnett County Office of Zoning Administrator d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as 7 :\ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m :� <br /> Ordinance, Sanitation Code, and withall other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a O <br /> Z-�W*m,tiAr _TZ170 <br /> O <br /> m <br /> m <br /> OER (Please Print).• ..•�� ���������� ������ ������.....����••.....•�•�•� CONTRACTOR or SURVEYOR or AG ENT.�•.••�•..•��������..���������� <br /> WNa <br /> .... .CsL......U�yss ..... ........ � - V <br /> .. .. ..................... <br /> ADDRE�SVC ADDRESS <br /> ��� .. .................. �/�Fi cSD fA _ c <br /> ADDR S ADDRESS <br /> ............614...........7& ...6s6 ........................... ..... . . . <br /> PHONE PHONE <br /> ........................................................................................... WEL. . . ..............LER....................................................................... <br /> PLUMBER L DRIL <br /> p <br /> ........................................................................................... ..AD.....DRESS..................................................................................... <br /> ADDRESS m <br /> ........................................................................................... ................................................... ....................................... 0 o• <br /> PHONE PHONE Z <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° S` <br /> 1, Work: No. Bathrooms v <br /> 2. New Building Details • •• o �^ <br /> New Building .,, Type of Cgns ucti No. Bedrooms .......... - \ <br /> Addition oo . „ �.c�� Septic Tank Size Gals. .......... <br /> .......... 1(1.......... ... . .. ....... ... .... <br /> SanitarySize .......r "-""'• <br /> .......... 4i..... ft. x ..../.,�.. ft. <br /> Fillingl Grading Height...8....... Stories . 4a. Absorption Field Site: <br /> ,,,,,,,, .�. i <br /> Moving .......... Area ............. . .. . ..4................ Soil .................................... - - <br /> i r <br /> o <br /> Slope ` 0 <br /> Mobile Home .................................... ..... . <br /> Priv Pere. Rate ................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Well .......... hDry Well <br /> mot from arage, mQ1, etc.) "". -� <br /> Subdivision •..•••,,,. �o.t ,d,� Seepage Trench .......... <br /> ........................... ........................ <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc., should be, sketched in Fig A. Include road I�t <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING = o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> __________________________________ —______—___________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... a m <br /> O <br /> O`- J <br /> 2-LC) 330 <br /> t a <br /> 1C <br /> 64' i"So 0 <br /> d <br /> a <br /> M N r rn m Z <br /> n <br /> N c- <br /> < m c m <br /> F <br /> m <br /> ZO O D a <br /> o oa ` 3 <br /> �v .� <br /> m <br /> 0 <br /> ...ate �.... . o <br /> Signature of Owner or Agent Date X <br /> Remarks ........................................................................................................................................................... m.............. ro � p <br /> m : <br /> ........................................................................................................................................................................................ . . . . <br /> ...............................................................................I........................ .... <br /> -�_Q^ m � NM <br /> .................. <br /> Inspection Date ....................................... ... .�L / i u, u, o u, o u, En <br /> { <br /> Zonin Admin strator F✓ 8 0 0 8 8 S h <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 percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, rlo any plumbing 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 the Zoning Adm inlstratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />