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Burnett County Office of Zoning Administrator eo z <br /> 0 <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 located as < H 0 :d <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c °uj <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the lawsandl regulations of the State of Wisconsin. 3 oa <br /> i .......l.C�. M o.'� . .... X.1.Qr..l. H m <br /> d ^ O <br /> ....................... <br /> OWNER Iplease print) IN or SURVEYOR or AGENT <br /> ADDRESS ....................................................... iu <br /> ADDRESS <br /> ............................................................................................ <br /> ADDRESS � �lJ <br /> ADDRESS ; <br /> .... .3?...-.asy!.................................................. ............................................................................................ <br /> PHONE PHONE _� 1 <br /> PLU..................................................................................... �J <br /> MBER ............................................................................................ <br /> WELL DRILLER <br /> ADDRESS . .......................................................................................... �_ '� <br /> ADDRESS <br /> 0 o <br /> _. <br /> . . .................................................................... .PHON.E.......... . ..................................................... 0 <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details No. <br /> New Building .. ....... Type of Construction: No. Bedrooms .......... ... <br /> Addition .,, ... ............ CK ,�,�, UD <br /> Septic Tank Size Gals. .......... r`\ <br /> Sanitary .......... Size .....lill... ft.. x ......!.X.. ft. .......... <br /> Filling/Grading ,,.,,,,,,, Height..O........ Stories ..!............ 4a. Absorption Field Site: <br /> Moving Soil Type .................................... <br /> .......... ......R. . ..49F .............. r i <br /> o <br /> Mobile Home .......... Slope .......................... ............... � �+ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> well ....... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ......... Seepage Trench .......... <br /> ...... .. <br /> Camping Unit (��'�/'��yt Privy .......... i <br /> .......1,..l.Sy:l.... . .......................... Seepage Bed ' <br /> --------------------------------------------------------------- .......... .N <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 <br /> 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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _—_— ----------------- -------__—_—_--___--___—_—___---- 1 i 0 i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> .....<.✓.s.�... ft. x ..l..G.[..... ft. — ............................... sq.ft. ...............................................................................- ; <br /> m <br /> 7! �— <br /> \/I Q1 j <br /> k <br /> 'i so e <br /> mz <br /> Z° <br /> 0 <br /> d <br /> n r L :E N M 2 <br /> o d C <br /> m <br /> 2 ON' 0 D n m <br /> o n <br /> o : : <br /> m <br /> _............. ..................... ...........7 11 0 . c <br /> Signature of caner r Agent Date . . <br /> Re .............................................. . ................... ................................................. ................................................. m <br /> x <br /> ( �Oc 8 <br /> k..................................�P � _ . . <br /> � II <br /> ............................................................................................................ ....... .................. <br /> .......................................... <br /> Inspection Date ^' m x, m <br /> ....... ............. .9 ............ <br /> .. ........................ u o N v m <br /> onin Admin trator $ $ $ $ $ VJ <br /> NOTE: A preliminary site inspection must be made and Ite approval granted on all structures involving sanitary facili es <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attache to <br /> this application before a permit will be issued. Do riot purchase or install a septic tank, do any plumbing or start any bu Id <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 />