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Burnett County Office of Zoning Administr for0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 = <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Iocat d as 7 :OQ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lan Use 0 ? °(4 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 al •� <br /> I CO t122o s <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ...L............s.X....i.9`��................... .................................................................................... ....... <br /> ADDRESS ADDRESS 1 <br /> ................................................................................... ....... <br /> ADDRESS ADDRESS <br /> .............................................. .................................................................................... ....... <br /> PHONE PHONE <br /> ........................................................................................... .................................................................................... ....... <br /> PLUMBER WELL DRILLER ` \ <br /> d <br /> ADDRESS ADDRESS n o <br /> ...... 0 <br /> ....... o < <br /> ........................................................................................... <br /> ............................................................................. . <br /> PHONE PHONE Z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms v i <br /> 2. New Building Details •• •""" '" o ' <br /> No. Bedrooms a <br /> New Building ....✓ Type of Construction: '••••.•... <br /> Addition •,•.,••,•, Septic Tank Size Gals. .......... i <br /> Sanitary ,,,,,,,,,, Size ... <br /> ?...... ft. x ..ZAq...... ft. <br /> Filling/Grading .......... Height../.A...... Stories ....o.......... 4a. Absorption Field Site: <br /> Moving .......... Area ....................... Soil Type ........................... ........ <br /> .................... <br /> MobileHome Slope ................................. ........ .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate .......................... ........ :\ <br /> Well •......... home,garage, motel, etc.) Dry Well . ........ _ <br /> Subdivision ,,,,,,,,,, �7 q.2hCrE Seepage Trench . ........ <br /> ..... . ......................................... <br /> Camping Unit .......... .................................................... Privy . ........ ) <br /> Seepage Bed . ........ <br /> ------------------------------------------------------------------- -- to <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. IncludE road C <br /> Cn <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 -4�—' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O p' <br /> --------- — — ------- ------------------------- — <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...................................................................... ........ <br /> e <br /> C,--- _ _ _.--,s AeP7Jt r Alt m <br /> ft <br /> N o <br /> o <br /> D?i�E <br /> zy 0 <br /> 7r{ <br /> v ...� C.46nbE <br /> o <br /> / U <br /> SE <br /> CF m <br /> t <br /> sy <br /> Nd9M <br /> < <br /> Z oo � Da <br /> / .0 n <br /> EA <br /> hin <br /> A&.... ........ . .................. ....... ...................................... o c <br /> Signature of Owne r Agent Date <br /> X M <br /> Remarks ............. ............................... ................................................................................................................... . r m <br /> v <br /> .......................................................................................................... ....... ............... ... . <br /> 0t <br /> T <br /> Inspection Date ..... <br /> ....................................... .... ...........;.. ........... o )n ouio �n <br /> Zoning Administ <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, do any plu nhinq or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the inf rmation conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval oft e Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ND APPROVED. <br />