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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 1 3 �1 <br /> 51> <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and p 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements oflthe g i� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws land 3 3 <br /> regujations of the State of Wisconsin. n <br /> r <br /> n.l1,.S.....4.eeJ.1Q.............................................. ...... \.}, I ......L.. !o. ................................:.... ...... <br /> OWNER (please print) �/ I CONTpR AC�TjOR or SUR�EYYO/R or AGENT <br /> ADSx..L..f...aox...AL�.1.......................................... .AO.f.L.S.f�. . .......-�L!^..1L ............................Il...... d i <br /> 34 <br /> ADDR\ ,.... -Y...... `.:.`............................. .ADDRE�VL.(G.�y.....UUJ......JYc]lJ�................�...... <br /> i I ' <br /> ................ ............... ...... <br /> ........................................................................................... <br /> . .... ................................. ... .........L <br /> PHONE PHON.. ..E <br /> PLUMBER............................................................................ D <br /> W. ELL RILLER......................................................... L...... <br /> i <br /> p <br /> ......... . ............................................................................... .A...........DRES.................................................................... <br /> ..... ...... O <br /> ADDRESS DS 0 L1 <br /> O <br /> PHONE PHONE ZH r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 » <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> y <br /> New BuildingT No. Bedrooms <br /> ' o <br /> .......... YPe of Construction: '• ...... i <br /> Addition .................................................... Septic Tank Size Gals. .. ....... <br /> Sanitary .......... Size .............. ft. x .............. ft. .. ....... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ........4................... ....... o <br /> Mobile Home Slope .................................. ....... .. <br /> .......... <br /> Privy .•...,,,., 3. Use (describe exactly, 1 -family Perc. Rate ...........................I....... <br /> Dry Well <br /> Well <br /> home,garage,motel, etc.) <br /> Subdivision Seepage Trench ..L...... 0 <br /> .. ... .................................................... <br /> Camping Unit .................................................... Privy ..1....... <br /> ����•••�•� Seepage Bed <br /> ----------------- -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. A. :w C I <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — :C 0 <br /> ___________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: Q <br /> ................ ft. x .............. ft. — ............................... sq.ft. ......................................................................1........ :� i <br /> pm"achek0 71� <br /> YI ID <br /> 0 <br /> f <br /> 1 U <br /> T <br /> Z Z <br /> O <br /> 71 <br /> y <br /> m <br /> m co. m w o c c -0 <br /> 07 <br /> —'' nm <br /> < Zc <br /> sap <br /> a y 533 <br /> G 0 0 G <br /> Z > -� <br /> o c m <br /> 00 O <br /> x m <br /> ........................................................................... ...................................... <br /> Signature of Owner or Agent Date o <br /> Remarks <br /> ..................................................................................................................................................................................�. � : o <br /> ................................................................................................................................... .. . .. ... ......................... ... <br /> w 'n <br /> Inspection Date ....................................... ...`.�'�,,. . . .q.. �..... . ., I..... o o m <br /> J //WC/1 .,. :... . <br /> 1 g . 9898 (a <br /> Zoning Adminis for �7/T <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 beem 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 />