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Burnett County Office of Zoning Administrator 0 Is o J o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o Q <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as '� N <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 with all other applicable County Ordinances and the laws and regulations of the Stat of Wisconsin. 3 <br /> f'Y �ir t lit 4 VA ` EO <br /> ... ..... ... p <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT o. <br /> 1 <br /> .. . . ...��. �. ,a.....5f4Kp[.x.4. .,4....................... .............................. r.....d.!.U` �........................ <br /> ADDRESS ADDRESS <br /> hPn SC �OK1 on S5 / � W.�S�2r SIL <br /> ' CI � . <br /> ....................................... ................................................... ............................................................................................ �\ <br /> ADDRESS ADDRESS <br /> .......................v.1. .-..72.e?'..aao(o................. .................. ).. ................. , <br /> PHONE PHONE <br /> .......... <br /> ....................................................... ............................................................................ <br /> PLUMBER WELL DRILLER : <br /> O <br /> ........................................................................................... . ....DR....ESS*S"*E*S* <br /> ........................................................................... _. <br /> ADDRESS AD.. n o <br /> ........................................................................................... ............................................................................................ o' <br /> PHONE PHONE Z N � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... i�u o <br /> New BuildingNo. Bedrooms .......... � o <br /> ..�.... Type of Construction: I : m <br /> Addition C9o- �.7ood Septic Tank Size Gals. .......... * i i <br /> r z- <br /> .............. ...`.`0................ < <br /> SanitarySize........., "•'•"' <br /> . �.y..... ft. x ..��..... ft. •• <br /> Filling/Grading .......... Height..J.t!... Stories ......f........ 4a. Absorption Field Site: i <br /> .. � Soil Type .....................Moving .......... Area ............' .10... � ..... Slope ........................ .......... <br /> Mobile Home ,,,,...... .... ................... r° <br /> i <br /> to <br /> Privy .......... 3. Use (descri exactly, 1 -family Pend. Rate ................................... <br /> Well .......... home arage, otel, etc.) Dry Well .......... 0 <br /> Subdivision .......... Seepage Trench .......... i <br /> ............................ .................... <br /> Camping Unit .......... � Privy .......... <br /> ...... �i�'0. �.......................... + <br /> �] Seepage Bed .......... �� <br /> ------------------------------------------ -------------------------- cn <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched In Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- UI a <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING 1� o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i o <br /> ---------------------------------------------------------------------- r <br /> 5. Lot Size: �7 Fig. A. 6. Lord <br /> aSion: <br /> /./. ft. x .. .g.�. ft. - ............................... sq.ft. :lTlc��ok......... ...... <br /> .................. �J+ <br /> �ite <br /> p n <br /> N O <br /> o <br /> s' <br /> VI l -E <br /> _ n (0,v l,-1 e_& G CL it On q_ \\ i <br /> V\ L: m ` <br /> U(:l,J ' c Z C <br /> Q_ o <br /> ere���t.� sus ✓ � <br /> 4 <br /> .Lr Z <br /> a,r�a� V �. o a ' 3 <br /> V,coCa <br /> Signature of Owner ornt Dat) — <br /> / 77 <br /> Remarks 5. roc'�1�..:....t .......... ...... eei\ .. .tT!o.!^'�...5(.G!.�.....�O.L... r 'T' x <br /> ......... ........... ( ....1... �. ....i............. <br /> ...................................................... <br /> ............................................................................................................... ...........././. ................................................. -1 . . . . m <br /> Inspection Date ....................................... �f.?.7....Z. . fr.�i. ..: .. E I` N W m <br /> ...................... u a o a o <br /> Zonin Administrator g o o g o o y <br /> NOTE: A preliminary site Inspection must he made and site approval granted on all structures Involving sanitary facilitiuS <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, do any plumbing or stair 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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />