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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q ; T- <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ° i LT\ <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 ^ a <br /> I : t ' n A,.? A 'TI I4�.$ .. ZY. ...... A <br /> .:. .......... ... ................................. E <br /> OWNERe�pplease printfl� CONTRACTQ,RorS RVEV or AGENT R <br /> "'1'AZ ROUT:.. BC 1�-r1YB .� 2 9j`� <br /> r <br /> g <br /> ......................................................................................... . ..ADD....R. ES'E'S"S........ ............................................................. ...... <br /> ADDRESS m <br /> f'CZ <br /> .........i?. .Q.11T,4 Za....i�....r1. .,01.................................. ..................rS.'-"�.4�� .i.r....Yi.Z....rJ.a:V.�.�,................... ...... -X- <br /> ADDRESS ADDRESS <br /> 715.-635...7595................................. . <br /> ........................................................................................... PHONE <br /> PHONE <br /> . . ...5r.r....H2„,I(1........................................... ....................................................... .... i ih <br /> ............ .. ... \" <br /> PLUMBER WELL DRILLER <br /> P. O .BCY 71.t... �CN .r.....'iL..S.? 80.1 ... . . . . ....................................................................... ....... v, <br /> ........... ....................... . . <br /> ADDRESS ADDRESS n o <br /> ............7.. 5.-G.3.S....7.5.9.5.............................................. <br /> PHONE PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details .. """' o <br /> zl- <br /> New Building ,,.,,,,,,, Type of Construction: No. Bedrooms <br /> Addition Septic Tank Size Gals. .. . .. .. <br /> .......... .................................................... <br /> Sanitary ...4.... .. ....... <br /> Size .............. ft. x .............. ft. i <br /> Filling/Grading .......... Height............. Stories ............... <br /> Soil Type ............................ ....... r i <br /> Moving Area ........................................... - o <br /> Mobile Home .......... Slope .................................. ....... <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... m <br /> Dry Well m <br /> Well ,......... home,garage,motel, etc.) " """' <br /> Seepage Trencho <br /> Subdivision ....... ........ ...... <br /> Camping Unit Privy . ...... <br /> e <br /> Seepage Bed . .... 2 <br /> ----------------------------------------- -- 1 •til <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. ` r' <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is loca ed at _ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. `„ 0 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> __________________ _____ __ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> �J �I <br /> ATTACH ID SHEET G <br /> N O <br /> O it , J <br /> J \r <br /> J T <br /> O J <br /> O <br /> . J <br /> N S <br /> II/I <br /> \ T <br /> Z <br /> 0 <br /> S <br /> v <br /> c <br /> m <br /> 1. <br /> :F <br /> N c MN f > W ca rill <br /> MI <br /> O < ' d C y J J <br /> 0 <br /> Z o D <br /> O NJ N i 9 <br /> c o0J . <br /> m � C <br /> o l - <br /> m <br /> OCT 26t1987 A v <br /> .......... .....o.f...... .. ... <br /> A..gent..... ... <br /> ............... <br /> ............ <br /> . ..... <br /> ............ <br /> D...at.... .......... .. <br /> Signatur..e Ow..ner.. ..or.. e o <br /> o ; <br /> o , <br /> T N <br /> Remarks <br /> ................................................................................................................................................................................. ...... <br /> o ; S <br /> ® : Nm <br /> Inspe,^tion Date ....................................... ........... . .... . . <br /> Zoning Admi istrato : 8 888 g $ 8 fm/1 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f icilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap lication 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 be n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans o 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 />