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Burnett County Office of Zoning Administrator 01 iu o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 �TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as — o y <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation <br /> Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> .......................................... ......... . . ........................................................................ _ <br /> a <br /> O NER (please print) CONTRACTOR or SURVEYOR or AGENT ai <br /> r.y. �.... .... <br /> . .. <br /> ....D..r......................................... <br /> . . ...... .....................................................................................�.1... .. <br /> ADDRESS ADDRESS <br /> . ........................ ................................................. ................................. ad <br /> U�nt <br /> 1,... ...... 4 ....... ti .......S53 ; <br /> A1(�P/D��R/ESS �L�yvy� (� ADDRESS E� 1 ' E-S <br /> PHD(l!.!.. .....1.•.V.../............,(„��0 A..D...D..R. ESS <br /> .PHON.E................................................................................ <br /> v <br /> �5.....�er. r C <br /> PLU BER WELL DRILLER <br /> 6.s�r v <br /> t c�.e.............:...................................................... ............... <br /> ADDRE S ADDRESS � � S <br /> - <br /> PHONE . .......................................................................................... �Z <br /> PHONE � ' <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms 1 7 rt <br /> New BuildingType of Construction: No. Bedrooms �.. <br /> Addition .......... .................................................... Septic Tank Size Gals. 77,10 i <br /> Sanitary y Size ft. x ft. ••' •' <br /> .,r�.... .............. .............. �p <br /> Moving <br /> ...... Height............. Stories ............... 4a. Absorption Field Site: 11 <br /> Moving .......... Area Soil Type .................................... '' r <br /> Mobile Home ... ...... Slope ................ ......................... <br /> Privy ,,.,,,.,,, 3. Use (describe exact) -famil Perc. Rate .......( .......7.-7.... <br /> Well .......... hors,garage, motel, etc.) Dry Well .......... .` <br /> Subdivision / V f Seepage Trench E <br /> LSC V .......... _ <br /> --Camping Unit .......... Privy ...... �l <br /> Seepage Bed .. ... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig_ A. Include roadCT <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 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING pp <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 1 o 0 <br /> ___---__—_----------------------------A---------- M <br /> 5. Lot Size: Fig. A. 6. Location: ''1 <br /> ft. x .............. ft. — ............................... sq. ft. ............................................................................... r1I ' 111 <br /> u <br /> 0 <br /> N o <br /> J � N <br /> o <br /> O <br /> z <br /> O <br /> C v <br /> X VI r T rn to Z <br /> so <br /> D - m <br /> o N. s <br /> o <br /> ea�° am 3 <br /> 7% _ �l � m <br /> kA.............................. ......- --................ 3 LAIC- O 7 <br /> ............................... ...... 0 <br /> 0 <br /> Signature of Owner or Ag nt Date J° C <br /> ... X 77 <br /> Remarks �/1.v <br /> �L..0CG..Z.:.{:..�.`.................................................................................................................................... �' m <br /> � O <br /> ........................................................................................................................................................................................ fA <br /> ............................................................................................................. <br /> n <br /> . t d �� m <br /> Inspection Date m{ 7 . . ...................... a <br /> m <br /> Zon g Administrator g o 0 o y <br /> NOTE: A preliminary site Inspection must be made a 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 dry 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 Ire made without approval of the Zoning Administrator_ <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />