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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT ; 3• (�► <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of Wisconsin. » g <br /> W/1, LIAM ....f-{.� RcuEL� S � / ............................................. � <br /> ........... ...... ................ ......................... . <br /> OWNER (please print) p CONTRACTOR or SURVEYOR or AGENT <br /> CTY- U U....Q So 9 ................ ...... a E <br /> .......................................... .................................... r <br /> ADD ESS J1I, ` ADDRESS <br /> ...QL.�..lr................W.4....C..�............ ................ y <br /> I <br /> AD ESS •�••���������� ADDRESS .•••• ,_1L V .p <br /> 7..!. .....3...., . ...........e4l..s............ ..........................................4.... <br /> PHONE PHONE <br /> .. . ...... ............................................................................... .............................................................................. ...... ...... <br /> I ice\ <br /> PLUMBER WELL DRILLER 4Z <br /> i� <br /> v <br /> T_. <br /> AOORESS ADDRESS n O <br /> N <br /> ........................................................................................... .PHONE <br /> .................................................. ................................ ...... 'Z <br /> PHONE <br /> DESCRIPTION 4. SanitaryFacilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ._ ...... c i <br /> New Building <br /> No. Bedrooms ...... <br /> o ... .. Type of�Lp struction: E>g <br /> Addition „••,•,.,, , , , 'fes ,!`R„w„�f. .......... Septic Tank Size Gals. <br /> ... . . ......y... . .. <br /> Sanitary �.. Size ...... ft. x ....5�.. ft. <br /> '` ' "' 4a. Absorption Field Site: ' <br /> Filling/Grading .......... Height............. Stories ............... {� <br /> Moving .......... Area Soil Type ............................ ....... c i <br /> ......................................... <br /> Mobile Home $lope .................................. ....... w .. <br /> Privy „ ,,,,.... 3. Use (describe exactly1 -family Perc. Rate ........................... ....... ° <br /> Well .......... home,garage, motel,at . Dry Well .. ....... m <br /> Seepage Trench Z <br /> Subdivision ” """' ° <br /> Camping Unit .......... .....................................4.............. Privy <br /> Seepage Bed ( • ti...�,(, Ut �+ <br /> -------------------------------------------------------------- -- ' <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. �A. <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local d at C <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. `— <br /> CLEARLY LABEL EXISTINGSTRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS_ 0 <br /> _ <br /> 5. Lot Size Fig. A. 6 Location j i <br /> ....... ft. x ......... ft. ............. sq.ft. -� <br /> 9 <br /> Sic,.t <br /> TOwell <br /> „ <br /> �kZt <br /> d <br /> F_ <br /> m (nv (nr Dmm -0 <br /> `1 f o wv <> 0. > o E. Em <br /> y Q '('� •� m Nn — am nny <br /> J Oat �( ° <br /> 0 <br /> a = o : O <br /> �/ x r, : o <br /> t...................................... <br /> Signature of Owner or Agent Date e <br /> Remark, <br /> ...L .a../. ..................... ....................................................................................................................... ..... r: ; <br /> o . o <br /> 0 0 <br /> .......................................�.......................................................................................... .......................................... .. o : T <br /> ... ... _ <br /> ,''lJQn-,,' .... Y I N tt N 8 0 N <br /> Inspection Date ..`7:..^�.... .......1.. ........ ....... .. . ..1....'1'UNI L4. . . .... ....... . qN fT O O O N m <br /> Zoning Administra or i r 8 8 0 8 0 8 U) <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 ANDA PROVED. <br />