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�d�7 .C's"I- I . <br /> Burnett County Office of Zoning Administrator 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < H �' <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 1 e ;� <br /> Ordinan- "anitation Code, and with all other applicable County Ordinances and the lawsandregulatioEN <br /> e State of Wisconsin. 3 a <br /> ...........:..J.:. . ............................ <br /> N 'a <br /> ........................ .................... . ................................... . ..................... {... A OWNER lease print) i• CONTRACTORorSURVEVOR oA <br /> ADD SS //• ADDRESS m <br /> itt�`��-• <br /> ADDRESS ADDRESS <br /> .2yc8- <br /> ...... ............ ............................................................................... <br /> PPHL. UO. .MN.EB..E. .. . .. .... .. . . . . . ....... <br /> . PHONE E <br /> ..... ...... DRILLER .............................................. <br /> . .. ...^.. .. ... . ... . ..... . .... <br /> O <br /> ADDRESS ADDRESS : 'q C) <br /> ........................................................................................... . .......................................................................................... ( 0 ri <br /> PHONE PHONE Z H r <br /> DESCRIPTION 4. Sanitary Facilities: ( ° o ° <br /> No. Bathrooms .... .... ^sn'� <br /> 1. Work: 2. New Building Details ^� o <br /> No. Bedrooms O � <br /> New Building ... ... Type ofstructi : Septic Tank Size Gals. ........ <br /> Addition ..... .............../� .................... <br /> Sanitary .... Size ....`a,O.... ft. x ALI...... ft. <br /> r.... <br /> Filling/Grading .... ..... Height............. Stories ............... 4a. Absorption Field Site: <br /> g Soil Type .................................... !�{ :(a <br /> Moving .......... Area ........................... ............... ;�', <br /> Mobile Home ......... Slope .......................................... <br /> Privy 3. Use (describe exacfamily <br /> Pere. Rate ................................... <br /> Well home,garage, motel, .) _ Dry Well ......... V <br /> ... i <br /> LSeepage Trench .......... <br /> Subdivision .... ....................... i <br /> Privy <br /> Camping Unit <br /> .......... .................................................... Seepage Bed ti3-- <br /> ___ <br /> Location of proposed structures and existing structures, well sewage systems, roads, etc., should be sketched In Fig. A. Include road W on i }� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter a A <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING :A <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. in O <br /> __.-------- ---------------------------- _ _--_— <br /> 5. Lot Size: Fig. A. 6. Location: :A <br /> . ...... ft. x ..3.3.9 ft. . ............................... sq.ft. ............................................................................... Vu <br /> P <br /> C <br /> 0 <br /> 11,.w e ! I <br /> j <br /> ilb <br /> OL <br /> Qj <br /> Ow Y ' A <br /> T <br /> e <br /> >) 0 - a v+ mZ <br /> F <br /> m Nn C'< <br /> m _. m <br /> Z oo' nn70 <br /> o <br /> o' ' -•I <br /> O � <br /> C�� a <br /> iso C <br /> m <br /> ............ Owner .... .................................. ...................................... x <br /> Signature of Owner o nt D <br /> A ate ' ' <br /> ... � : " <br /> .............................................................................................................. . : : : . .Remarks <br /> ! LO <br /> on, <br /> ................................................................... ...................................................................................................I.............. <br /> . ............... . !� ...... <br /> Inspection Date .:.... ...................... <br /> ator............ ..................... <br /> Zoin <br /> N o ro T <br /> NOTE: A preliminary site Inspection must be made and site approval granted on all structures involving sanitary facillties <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 ISe made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />