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Burnett County Office of Zoning Administrii for �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' 3 <br /> d ,; <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •2 M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the '7 i <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of <br /> .19./r..L.. . Wisconsi CX � 9T.1 ... - ..................................................................................... ..........0KN � . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> l.]. (E.t.... .. .... .. gx...Z.Lz.... ....... ........ ................ .............. .................................... ...... 'a f <br /> ..... . ........ ...... ^ <br /> ADDRESCSQ ADDRESS <br /> ....W.g.h'.S.T. ..R.tt......S.Y..i.M..N..<..�s! 8.9,s..1 ... . ... . . . <br /> 1 <br /> ADDRESS ADDRESS .^ fi <br /> . .. ... -T'f/.. ils <br /> ................................................. . . ................................................................................. ...... 717 <br /> PHONE PHONE :r <br /> ........................................................................................... W . ..ELL...D.RI..*L"L"E"R................... <br /> PLUMBER <br /> O <br /> ADDRESS ADDRESS m 0 <br /> n O <br /> ........................................................................................... . ............................................................................ ...... <br /> PHONE PHONE........ Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° _ <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New BuildingNo. Bedrooms <br /> .. Type of Constru ion: <br /> •••••• <br /> Addition ,., , , ! Q{�•G Septic Tank Size Gals. ... ...... <br /> Sanitary .......... Sx .............. ft. ... ...... i i�C. <br /> Filling/Grading Height............. Stories ...... 4a. Absorption Field Site: <br /> Moving Soil Type .................. <br /> .......... ......................................... ......... ...... .o � <br /> Mobile Home Slope ................................... ...... o <br /> .......... <br /> a <br /> » :1 <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............................ ...... t,lJ i <br /> Well .......... home,garage, motel,etc.) Dry Well ... ...... <br /> Subdivision ...,,,,.,- Cn Seepage Trench z <br /> A � <br /> Camping Unit ,,,,,,,,,, Privy ... ...... yJ <br /> ....... ............................................ Seepage Bed ... ...... <br /> _____________ _____ __ __ 1 - <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fit. A. :d <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :C <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. „`—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ------ ------- _ i E <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. — ............................... sq.ft. ....................................................................... ....... <br /> 0 <br /> _ hors e� Sox Cab I <br /> a <br /> \ D a M Nf- D W •fl <br /> A �QGJ 7O -M EL . ms <br /> o � <br /> ti M <br /> oD <br /> . .... L in <br /> Signature x m <br /> A : <br /> ........ .... .............. G <br /> Signature of Owner or Agent Date <br /> o , <br /> T: <br /> N : <br /> Remarks ............................................................... a <br /> ............................................................................................I...........?0' <br /> .................. .. ...... ........ ... ............. ... o . <br /> Inspection Date ....................................... N N o <br /> ... .. . .Zonin Administr for8 8 8 8 rnNOTE: A preliminary site inspection must be made and site appranted on all structures involving sanitary fac lilies before constructi n <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 pecifications 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 />