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Burnett County ' Office of Zoning Administra or <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a <br /> 0 o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd '� q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he o i f1 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> re <br /> gtions of the State of Wiscon <br /> � ................5.. ... ........................................... ..... :o <br /> . ........................................Ipleax print) CONTRACTOR or SURVEYOR or AGENT �� ,``` • <br /> . .r......!�.t........8°.X....l...9..s:....................... <br /> . . . . . . ......................................................................... ..... y <br /> ADDRESS xnn ADDRESS = I <br /> d b nl"t r ..�`-? .. .SJO.I. •c <br /> ........... . ................................................................................... ...... ? ' <br /> :7 <br /> ...... ............................... . ..... ADDRESS I :.e <br /> ADDRESS <br /> in <br /> PHOE.......... ................................................................... .PHONE...................................................................... ... <br /> aP ,ris <br /> .......................................... ...... <br /> ... .................................................................... .WELL DRILLER <br /> PLUMBER - <br /> O <br /> . . . ......... ............................................................... <br /> ........ <br /> ADDRESS ADDRESSN c <br /> _ < <br /> ........... ...... ...... O <br /> ............................................................... ...... O . . . . .i <br /> G N C 'ZJ\ <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: o � <br /> / 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .. •••• :d o 1 <br /> New Building ....L/ Type of nstruction: No. Bedrooms �•• '• <br /> .,•,,,•, ,,,,... .. h Q."s:Y!. Septic Tank Size Gals. <br /> Tj <br /> Addition ..f� ? <br /> �� 1 <br /> Sanitary V Size ..=1. ......... ft. x ............ . ft. <br /> Filling/Grading .......... Height..ae...f .... Stories A.......... 4a. Absorption Field Site: i <br /> G.a �c Soil Type ............................ ..... . r <br /> Moving .......... Area ........................... ..... ........ .. <br /> 0 <br /> PerP. .ate ....... <br /> Mobile Home .......... .................... .... .. <br /> Pert. Rate ..................... . m <br /> Privy .......... 3. Use (describe exactly, -family Dr Well }�,� 0`t n <br /> Well home,garage,motel, tc.I y err r' Z y ' <br /> ••"""•• Seepage Trench .. ....... <br /> Subdivision .......... .........Efleri ..... Privy n <br /> Camping unit ........................... Seepage Bed . ........ Ij <br /> t� ►cr1� <br /> ---------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fi . A. :l'U � y <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota ed at — <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. y`-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> -------------- -- <br /> 5. Lot Size: g. �q{� <br /> ................ ft. x ............. ft. — sq.ft. .......!+J.f.6..P.d<1P'.+c-i.�. 1: . ....... Q <br /> ............................... Fig. A. 6. Loc <br /> `•o <br /> C <br /> to Pa-& tj ZtJ/VI d��� �� a � <br /> p w aerr '� _ — -4 sv <br /> oAJ,51 l /PUSf e-,^� log <br /> 71131 V: <br /> T <br /> c�we`1 n� <br /> T be o <br /> so ' T Offw"-► " c <br /> l/� �V D O o R O O ...I <br /> 0 <br /> o 0 <br /> . . m <br /> . .... <br /> .............................. ...................................... > O <br /> 9 <br /> Sign ture of wner or`Agent Date o ' <br /> o , <br /> m H <br /> N <br /> Remarks ................................................................................................................................................................ ........ m ,. <br /> ....... ._+ o : p <br /> 0 <br /> 0 0 <br /> o : <br /> m <br /> Inspection Date ....................................... <br /> ......... ........ S 8 8 8 8�O NN <br /> m <br /> n dministrator.................................................................. Zonito <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary acilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this a plication before a permit will <br /> be issued. Do not purchase or install a septic tank,do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />