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0-2�C0177 <br /> Burnett County Office of Zoning Administrator -{ (/z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> d o <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 no <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 tDa A �� <br /> ti _ <br /> Dal ...................N..l.tm..�................................. . .......................................................................................... � o <br /> .. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m m <br /> 1.31.4........ .. N... .:......................... ............................................................................................ADDRESSa <br /> �- 4 <br /> IIAA ADDRESS d <br /> .6 <br /> ...�.�.. .....rl. ,SSS/3.r.'.l........................ .ADDRESS. . ............................................................................ <br /> .qn' . � ..y . ................. . . .. :r <br /> DDRESS <br /> ..... <br /> ...[.. ...4Z .......Y.,: s........ �......................... i i� i <br /> PHONE PHONE ' <br /> ............ <br /> PLUMBER WELLDRI LLER r1 <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... O <br /> ADDRESS — <br /> m 0 <br /> n O —a <br /> .... ................................................................................ PH.ONE < <br /> PHONE . ..................................................................................... _. <br /> � <br /> DESCRIPTION o <br /> 4. Sanitary Facilities: ! o <br /> 1. Work: NBth <br /> 2. New Building Details o. arooms <br /> New Building T No. Bedrooms ..�r�...... Mo <br /> Type of Construction: <br /> Addition ..�(.... . . ............................................ Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft. x ft. ... <br /> Filling/Grading ...,,,,•„ Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ......................................... Soil Type Xq.N.d.................... <br /> 0 Mobile Home ........ . Slope ...... .................. ............. ,. <br /> Privy Perc. Rate .je .' Nlh... ..(.rf,..... . <br /> ........., 3. Use (describe exactly, 1 -family <br /> Well home,garage, motel, etc.) Dry Well ,.......,, -11- <br /> .......... <br /> Subdivision .F,C l��L ego- - L Seepage Trench .......... 54 <br /> Camping 9 .......... d/..*l.i..!1 ...CJ..'F•�.........1 l Privy t <br /> -----------�--5 a -m Seepage Bed ....... <br /> -- ------- ------- .. <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 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 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS, iD <br /> O 5 <br /> 5. Lot Size: D Fig. A. 6. Location: f <br /> kll .!!........ ft. x .`.Z.t?...... ft. . ...............I............... sq. ft. .........................1..-................................................... <br /> Lakes Uls.u9 I` — � <br /> I <br /> Ler- if/2r.•�� <br /> 3�2� _No. <br /> I�Tn1 SDP ��' <br /> 7-/'7 q <br /> Cabf/jC�ooeG µ ar -R <br /> rlN9 <br /> ��C s seK t♦ 3`, <br /> er <br /> Q <br /> bsta ! n T UJaG t � <br /> IdPS <br /> W10C4-r boTT r $c?�at1lsAW <br /> l4 yHy <br /> J ® aT <br /> DdQ <br /> ANT 'rm <br /> TcI.eeL rofore A <br /> o <br /> H't rK w�:v`t <br /> "s kC . <br /> — n <br /> ®� (� 00 ' <br /> � oro <br /> SQ�Ti C �f an <br /> i-a n K m <br /> m <br /> Signature of Owner or A ant Date I° C <br /> IX : �7 <br /> Remarks ......................................................................................................................................................................... T m <br /> O <br /> ........................................................................................................................................................................................ <br /> ......................................................................................................... .. .................... . 1........ <br /> ................. � <br /> Inspection Date ....................................... T <br /> �.?r�.l'� I .. . . .,� U o U ' m <br /> � . ... ........... m <br /> Zoning Adminisir or (� n 8 0 0 0 y <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 riot 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 it misrepresentation of any of the information conveyed here <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator_ <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />