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7- 3 <br /> Burnett County Office of Zoning Administratorv 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requ,rements of the Burnett County Lad Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wis onset. <br /> In({'d� � I <br /> OWNER(pleas�ntlll 4'. .f. F) I CONTRACTOR C I or >' /V ` OR or — m O <br /> ll ff J l l Il �j <br /> C ... <br /> ACTOR or SU VEVOR or AGENT a <br /> .. <br /> 1. ....I .....� �.. F ... ...... .... .............. . .. <br /> ADDRESS J) AD gESS <br /> ( <br /> 4 �i.iG. ... ....r ... ... ..... I 1.. ,.!f.................i .. Sr <br /> ... ..... . . ......... ..... .. . .. .......... . . . .i.. ... . <br /> ADDRESS ADDRESS °`r i t <br /> Y- <br /> ..................................................._.......................... ......... i 1 <br /> PHONE PHONE <br /> ................................................................ ... <br /> PLUMBER WELL <br /> O r- <br /> ADDRESS ADDRESS o <br /> ........IF .............................................................................. <br /> ............................................................................................ o 1 <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .... ' `. o <br /> New BuildingType of Construction: No. Bedrooms ..5 �- - Z D <br /> Septic Tank Size Gals. <br /> Sanitary Ak: Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ......I... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... c r i <br /> P <br /> Mobile Home Slope ................................. ° <br /> ,,,,,,,,,, <br /> OE <br /> Priv Perc. Rate ................................... <br /> Privy ..... 3. Use (describe exactly, 1 -family , <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> subdivision .......... .................................................... Seepage Trench .......... - <br /> Camping Unit .......... Privy .......... G: <br /> ............................................... Seepage Bed Ui <br /> -------------------------------- S'V w <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched In Fig. A_ Include road I Q �1 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- -Ira <br /> : <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. V o ` <br /> . ft. x ... ft. — ... ...-----Sq f . <br /> A. 6. Location . ...---- <br /> t. <br /> 5. Lot Size . ... <br /> n <br /> 9.s <br /> No <br /> O 173: J <br /> "J '✓ 0 <br /> rll J <br /> S <br /> O <br /> T <br /> z <br /> I � <br /> � J <br /> U1 <br /> N <br /> x11 <br /> m N e- <br /> Z o o D n m <br /> o J n aJ <br /> _on _ <br /> m <br /> %. � <br /> ................ ........... _ p <br /> ° <br /> Sig lure of Owner or Agent Date <br /> Retrtarks <br /> m : <br /> fl <br /> 'u <br /> Inspection Date ....:.�.1.�.....-.G?...rc r.11�i,r<% IL'� . . 1..,�%Ly1ar.'„ia"1..�,.: .. U o N o m <br /> :.. .................. . ....... ........... .......... ?�..... ..... /. o o . <br /> Zoning AdminPstrator 8 0 0 8 8 8 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures iivolving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must he 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 no made without ap oroval of the Zoning A lm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />