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Gvi5 D T' Z> <br /> Burnett County Office of Zoning Administrator a o O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' 3 C <br /> ' a " o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as — :O,q <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use ; Q <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> o <br /> i <br /> a <br /> � ¢� d � s N µ <br /> OW ER (plea print) (r , , t CONTRACTOR or SURVEYOR or AGENT a <br />... .�.. .. .LSf.1.!'(. <br /> .{.�... ............. ..•. ............................................................................................ d •,/r <br /> ADDRESS ADDRESS <br /> ADDRESS............................................................................ .ADDRESS..... �W :n <br /> ....................................................................... <br /> . ..r . ...... ...................................... ............................................................................................ A. <br /> PHONES n PHONE :� T <br /> Q <br /> PLUMBER WELL DRILLER :\ ; <br /> O <br />........................................................................................... . . .. . .............................................................................. n .o <br /> ADDRESS ADDRES..S °U m G1 <br />........................................................................................... ............................................................................................ o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: p o o '-r•�I <br /> 1. Work: No. Bathrooms .... ' I <br /> 2. New Building Details <br /> New Building Type of Construe ' No. Bedrooms .......... Q <br /> Addition ,.,.,...., .....- ........... ,,,... Septic Tank Size Gals. .......... \ <br /> 17...... <br /> Sanitary ..X.... Size .............. ft. x .............. ft. <br /> Filling/Grading ..... .... Height........... Stories ............... 4a. Absorption Field Sit€: : <br /> Moving .......... Area Soil Type .................................... s, : r- <br /> 3 �p o <br /> Mobile Home .......... Slope .......................................... � 3 .. <br /> Priv Pere. Rate ............................ ...... E <br /> Privy ......... 3. Use (describe exactly, 1 -family >> � � <br /> Well ....,,,,., home,garage, motel, etc.) Dry Well ..ta..... �, [ <br /> Subdivision ....I..... Seepage Trench .......... ^r <br /> Camping Unit .......... .................................................... Privy ��Y <br /> .p.... S. <br /> .................................................... Seepage Bed <br />-------------------------------------------------------- --- ----- 1 k) •add <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A- Include road I :� e <br /> setback, side and back Y highway yard dimension and location and setback from all bodies of water. If property is located at a hi hwa inter <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS I -C <br />__...----------------------------------------------- �. <br /> 5. Lot Size: Fig. A. 6. Location: <br /> (,Q <br /> ................ ft. x .............. ft. — ......a O �Gr_t�a'sq. ft. <br /> O <br /> ' 2 : n <br /> .. o <br /> S <br /> Z <br /> e <br /> N <br /> 7J [A r 9 to m Z <br /> Z <br /> N) aa.� <br /> 13� (Nit <' C � � cm -0m <br /> z o o a a m <br /> o n am 3 <br /> E» - <br /> ap <br /> n C � m <br /> .�. -.�5s c <br /> Signature of Owne r Agent Date <br /> Remarks ....l... ./.Ll.../.. ..: 1 c:6L:..:.:.1'..f..l...y(.4..{.`...!!....C,.... t/1 . ......... . . ................. x . . v <br /> e <br /> <.r. .< . ��... . .. .«...: ....1._'..!..✓ ......�.� .. . .... ..� ./.V.. .. 1. ........ :. �:. �p ! <br /> - / ��{{ <br /> .. . .. .... ...... ..............Z........:..................................................... .. . ...... /..,./. ........................... <br /> SLG `1 <br /> fes' <br /> rn <br /> InspectionDate ....................................... .. .......:. ... ... .. .. .... . . . .......... m <br /> Zoning Ad nistrator <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 fie made without approval of the Zoning Administratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> V113 <br />