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Burnett County Office of Zoning Administratora o 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 — �A <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseQ C :UQ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M <br /> :...................... ....i,. .. ...... . F�.... <br /> Iu ...................................... <br /> OWNER (please print) CONTRACTOR or SORV O.R or AGENT o. <br /> ADDRESS . .....t.... .k..A........ .(.....—,../J{/2G%.d: !....K.G:..L................................................. <br /> ADDRESS / <br /> ADDRESS ADDRESS <br /> ........................................................................................... .... <br /> PHONE ............................................................................................ \ <br /> PHON ;� \\ <br /> ............................................................................. . . . ...........R...... .... . . . .... . . .. ................... <br /> ....... ..... <br /> PLUMBER WELL DILL.ER... ... ..... .... ...... ....... ..... ..... l'J <br /> ............................................................ E <br /> ............................... .AD... . . . <br /> D..RSS............................................................................... : O <br /> ADDRESS <br /> n 0 <br /> » i <br /> PHONEPHONE....................................... ....................................... � ? .: <br /> DESCRIPTION 4. SanitaryFacilities: ° o 0 <br /> 1. Work: No. Bathrooms i T i <br /> 2. New Building Details ��•� �� r> <br /> New Building Type of Construction: No. Bedrooms .......... o <br /> a <br /> m <br /> Addition Septic Tank Size Gals. .......... <br /> ... .......................... <br /> Sanitary <br /> .......... Size .............. ft. x ft. •........• <br /> Filling/Grading ,..,.,,.,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> o <br /> Mobile Home .......... Slope .......................................... : » <br /> PrivyPere. Rate ...........................I....... uv ;4f i <br /> .......... 3. Use (describe exactly, 1 -family <br /> Well ........., home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ,.,, Seepage Trench .......... <br /> .................................6.................. <br /> Camping Unit „ ,.,,,.., Privy .......... i ;n <br /> .................................................... _ <br /> ------------------- ------ Seepage Bed .......... U <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig A_ Include road I o •� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O 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. '—” <br /> 0 <br /> Fig. A. 6. Location: <br /> 5. Lot Size: <br /> - <br /> ft. x .............. ft. . ............................... sq. ft. _............................................................................... <br /> A <br /> 4' Co <br /> j 0 <br /> � y <br /> o <br /> Y F <br /> S <br /> Car06o <br /> �. <br /> M N r M m Z <br /> 11 f C� c m <br /> 1 i N o d N L m <br /> / Z o �: m Dam <br /> CalL / Us <br /> ............ .....,,// ........,,.. Z <br /> Signature of Owner or Agent v Date .i a» _ <br /> 1 <br /> Remarks 1C.:'.�t2!/li7.rs.<,4.-?fr.. .��ri..y. .......��0335 �.v -]�.�•�i+�.� x : M <br /> .................. ........................ .. ....... T : : : O <br /> ........................................................................................................................................................................................ <br /> � II <br /> :� <br /> �,: <br /> ......................... .. ............................................... <br /> c,. <br /> n: <br /> Inspection Date ....................................... QJ.u.'l,f. ",Ll�->�Q�nt_,�J ' i oNi cNn o umi o' u m <br /> Zoning Adffiinistrator ' . . $ $ $ $ $ $ to <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, rlo any plumbing or start any build- <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 />