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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> o <br /> �1I� ........ . l e ...:..................... ... ........................................................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT `\^ <br /> m \: <br /> 3y5/ ST /, . a x <br /> ADDRE5 ..................... .ADDRESS..........................................................................., m <br /> .............................................................. <br /> s !/.w. T�..... -...3."5. ..� ..... ................ <br /> ADDRESS ADDRESS <br /> .......................................... .......................................... ............................................................................................ <br /> PHONE PHONE <br /> G�. . ......W...� C,ISON................................... <br /> `� . ... . . . ..................................................................................... <br /> PLUMBER/ -_� WELL DRILLER �^J <br /> ..Y/3 SMrIN SI ,5poower wy S"/Pg/ .O <br /> ... ........................................... <br /> ADDRESS ADDRESS :'ij m M <br /> .......... <br /> ............................................................................................ <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .... o <br /> New Building ,,,, Type of Construction: No. Bedrooms .....�,,.. c.;W i <br /> Addition .......... .................................................... Septic Tank Size Gals. ?'6� <br /> Sanitary „!....... Size .............. ft. x .............. ft. F <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: T `1 <br /> Moving .......... Area Soil Type .................................... ?; r <br /> Mobile Home Slope .......................................... o <br /> Privy ..... .,,, 3. Use (describe exactly, 1 -family Perc. Rate ........L..�................. Y ! R <br /> Well .......... home,garage, motel, etc.) Dry Well q <br /> Subdivision <br /> Seepage Trench .......... t <br /> .......... ..f......a K!t1.✓.�.`1....................... t <br /> / <br /> Camping Unit • • <br /> ... <br /> .......... Privy <br /> .............................. ................... Seepage Bed ...� V, p' <br /> ------------------------------------------------- ------ cI .� <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road C a ;M <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <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. p' <br /> --------------------------------------------------------------- ----- <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> ............................................................................... o'° <br /> n <br /> n n <br /> N o <br /> 0 7( <br /> 3 <br /> W O <br /> V S <br /> T ;� m <br /> L m 4 <br /> Z <br /> 0 <br /> M <br /> m <br /> m <br /> M cnf T :E at <br /> M <br /> Z oo' na77 <br /> o <br /> ss <br /> m <br /> Signature off/ caner or Agent fj p Date �X <br /> Remark,S�J,PrGii�Y ..:TT...�a�J�y/ ...................................................................................................... <br /> r <br /> .............T . .. a.-v-......................................................... V <br /> 11 r <br /> ......................................................................................................... <br /> .... ................... . <br /> Inspection Date o "' ' °D J `�' m <br /> .......... . .......................... ..... ................^ ..... ............�...................... � g � gg $ <br /> Zonin A lnistrator <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 Arlin lnistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />