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Burnett County -- Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3' o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 ' <br /> regulations of the State of Wisconsin. a ) <br /> F. �.... . ... /, /............................. ...... se/f ................................................................ ...... - - <br /> OWNER (please prriintt) CONTRACTOR or SURVEYOR or AGENT <br /> ....�t4: ...../U.4............................................................... <br /> ..................................................................................... ...... m <br /> ADDRESS ADDRESS <br /> f✓in��/ _ ��( <br /> ......................... ..................................................................................... ...... <br /> ADD ESS / y ADDRESS <br /> .z.. ..7 . ...................................... PH...ON......E.... l •� <br /> �v .. 7�/ . . <br /> ...................................................................... ...... <br /> ... . .. . ................................................................ . i v\ <br /> PLUMBER WELL DRILLER � i <br /> �1-................ .................................................................................... .. o <br /> ADDRESS ADDRESSG <br /> h <br /> f - <br /> �.. FG . _. <br /> 7i.- . . .. .- aP. .............................................. ...................................................Y............................... ....... <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° c ° �G1 <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details " " "' o <br /> New Building .•........ Type of Construction: No. Bedrooms . . .... <br /> Septic Tank Size Gals. . ..�.. ' <br /> Addition .......... ..............)l//.--...................00,y� < <br /> Sanitary N' Size ....I.C{/... ft. x ...va..... ft. .. ....... ~� C�- <br /> Filling/Grading .......... Height............. Stories ..............., 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ............................ ....... <br /> Mobile HomeSlope ..................... <br /> .......... yy <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .............tf........... ....... <br /> Dry Well <br /> n <br /> Well .......... home,garage,motel, etc.) " """' <br /> Subdivision Seepage Trench o <br /> �.. .Q/Kf.. /�[YY1G......... <br /> �'/y' Privy .cZ} <br /> Camping Unit .......... ...........�......../..................... ..✓.. � <br /> ""'" Seepage Bed .. ...... <br /> ------------------------------ --- <br /> ------------------------ <br /> Location of proposed structures and existing structures, well sewage systems, roads, etc., should be sketched in Ft 1. A. ' <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. lft <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.------------------------------------------------------------------- -- i <br /> CJ <br /> 5. Lot Size: Fig. A. 6. Location: ' <br /> ................ ft. x .............. ft. . ............................... sq.ft. :C <br /> J <br /> tieJ 9t� <br /> M y <br /> N !V'T <br /> Z <br /> O <br /> A <br /> N <br /> J <br /> V7 <br /> m <br /> `� 31 C mNr- Dm m m <br /> O N � "'� � O m m <br /> Z O 2 D 1 <br /> p N J y n A <br /> o o m <br /> S m y <br /> x r, : m <br /> ........................................................................... ...................................... <br /> Signature ofOwner or <br /> Agent Date $ <br /> .5,.'�...L.✓ter• .�`- <br /> Remarks <br /> .... . . ........::........................................................................................................................................ `. <br /> "Gl 7 0 <br /> 0 0 <br /> .................................................................. <br /> ...................................... ..... ............... ............................................... ...... . : g : N T <br /> �`f .... N OCN + r <br /> Inspection Date ... ..... . .. ..��........ ... .... . ....... ..... . . . ................ . v, N u, O o N m <br /> Zo ing Administrator S 8 8 8 S S to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 be n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi 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 AF PROVED. <br />