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Burnett County Office of Zoning Administrator c --I z <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 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and' regulations of the State of Wisconsin. 3 M <br /> o`Ur a orJ l .Ed' Z�) n <br /> �l1... .............................................................. �................ :................ .............................................. 0 <br /> OWNER (Please p t) � C TRA TOR or SU RVEVO or AGENT a t„ <br /> ll.�:�.... !� ism <br /> .... ..... . . .............r.................. .. .........J......................... a ;� <br /> ADDRESS ADDRESS .. <br /> ....................... <br /> ............................................................................................ <br /> ADDRESS ADDRESS <br /> i i a i M1 <br /> PHONE................................................................................ .PHONE................................................................................ <br /> ........................................................................................... . . . ........ ... <br /> ........... <br /> ........ <br /> ........... <br /> .......................... <br /> .......... \ <br /> PLUMBER WELLDRILLER........ <br /> ........................................................................................... . .. <br /> A..D.D...R...ES........................................................ ....................... O <br /> ADDRESS S <br /> w O <br /> c ; <br /> ........................................................................................... ..........E...... <br /> .................................................. <br /> ........... <br /> ............... <br /> Z o .: <br /> PHONE PHON <br /> DESCRIPTIONr <br /> 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• ••• •• c <br /> New Building .......... Type of Construction: No. Bedrooms .......... a '• <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: n ' <br /> MovingArea ...................... . Soil Type .................................... r <br /> o <br /> Mobile Home .......... Slope ..........................................H a ^' <br /> Perc. Rate ...................................^ i <br /> Privy .......... 3. Use (describe exactly, 1 -family n, fl <br /> Well home,garage, motel, etc.) Dry Well .......... <br /> Subdivision . ,,, Seepage Trench ..........� ` r3 <br /> ............. ...................................... <br /> Camping Unit .......... Privy . . <br /> ............................................... ......... k p <br /> Seepage Bed i <br /> _ <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road .. c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter-2 a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING b . ,C c <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> 0 <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: F o c <br /> ................ ft. x .............. ft. . ............................... sq.ft. .............................................................................. w N <br /> Ns,f > e ° 0 <br /> I o. <br /> /CI <br /> r <br /> C)' <br /> V� iP� <br /> 0) <br /> o <br /> _ d <br /> \� Unl rr7 1 m <br /> \ :v <br /> ]J N <br /> m yr to Z <br /> m <br /> - m <br /> Z > a M <br /> U,0 � <br /> .................................... ...................................... .............................. . E C <br /> Signature of wner�orr Agent Date ' <br /> Remarks . !/.G �:GCt/r`.:� ... y� X . . . . Im <br /> ..... . . .. ................................................................................................................ m . . . . . : <br /> `C v <br /> [� . <br /> .... . . . . . . <br /> ....... ..... <br /> I � <br /> ... <br /> Inspection Date ....................................... . . .:... .. ........l..,f ::.... ...:`7! .......... .......... i ` o � 'o m <br /> M <br /> Zoning Ad Inistrator f 8 88 8 8 8 (n <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 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 />