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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� 12 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the $ e <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws knd 3 <br /> regulations of the State of Wisconsin. <br /> L4&JXIANeC / ),4/tfyn/ # 0 <br /> ................. . ..... <br /> ........................... <br /> OWNER IDlsese print) � CONTRACTOR or SURVEYOR or AGENT •�_ <br /> .................. C - <br /> ADDRESS ADDRESS <br /> EA .!3 !!�......!'�ti ss�zz I <br /> ADDRE ADDRESS <br /> ........................................................................................... .P.HOH.0"N..E............................................................................ . <br /> PHONE p <br /> . ................................................................................... .WE......LL...DR.. .ILLE. . . ..R.............................................................. ...... - <br /> PLUMBER <br /> ADDRESS ADDRESS <br /> n o <br /> .. ........................................................................................ . ' .............................................................................. ...... o <br /> PHONE PHH.O0NE Z r -� <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 ' <br /> 1. Work: No. Bathrooms v <br /> 2. New Building Details ••• •••••• <br /> New BuildingNo. Bedrooms <br /> 0 <br /> ....'; . Type of Construction: ..• • • <br /> Addition k 4i[?Q pSeptic Tank Size Gals. .. ...... <br /> .......... ......... i <br /> Sanitary .......... Size ....�y..... ft. x ....Z.�.. ft. ... ...... i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site, <br /> Moving Z.BJ r Soil Type ........... ................ ...... r <br /> .......... Area ...................... ?.................. ........ <br /> Mobile Home Slope 0 <br /> .......... ... ...................... ...... <br /> Privy .......... 3. Use (describeexactly,-1 -family Perc. Rat ............................ ...... <br /> Well , , , , home,garage,motel, etc.) Dry I ... <br /> Subdivision ........,, Lam¢✓ Pv�^^�-� age Trench Z <br /> .................................................... ... ...... o <br /> riv ... ...... <br /> CampingUnit .......... .................................................... y <br /> Seepage Bed . . .... 91-1 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. ^^ 11 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ..Y -' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> !OO.. ft. x .W.S ... ft. . .....`(,l Sot9 s f . tOr .a LakLr .. <br /> p .................. q. t ................................. ........................................ <br /> 0 <br /> o � <br /> O <br /> O <br /> 0° <br /> l <br /> 21 <br /> Z <br /> O <br /> v <br /> U) 71ud0C3 03 <br /> CC <br /> m <br /> m, Nn•c - <br /> c: nn <br /> dCyoo ; <br /> O N < M O O m <br /> O W O : D <br /> Nom . yn ' <br /> � 0 o <br /> c_ <br /> A 9 <br /> :: .:.. ...... ................ ...... ...... n : o <br /> Signature 4t of Owner or—A.gent. <br /> D ..ate o <br /> 0 <br /> T ' <br /> Remarks ........ C^ , ........... .. <br /> . g� <br /> 9.:::::::::::: .::::::/:1::::::::::: :::::::: :: :::::::::::::::: ::: . a » o <br /> ................................................................�...................................... ...................... ').... 8 m <br /> Inspection Date ....................................... ( 171 ...............7..� :/�. .......". U cn o <br /> Zoning Administr tlor g g g g Vl <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lities before construe ion <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 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 s Decifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />