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Burnett County Office of Zoning Administrator �' e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 71*' ;V <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and D Fy <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other'lippRcame Co t(Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. �- a <br /> Oryx. Cev n w <br /> Pico //yy L T \� <br /> eV............................... y....................1.(.y................... ... .......... .. ..........................:.................................... 4 <br /> OWNER (Dl print) V O NTRAor SURVEYOR or AGE 3 q <br /> 1 G . ........................................ ............. ..... . ........... . ....... ........:................ a �: >A <br /> h..... . ..... .......... .. . ... J S <br /> ADDRESS ADDRES � �{ '•,l i `O <br /> ��........................................................................... .AD DR ES ... ....t..: ..... .. ..... ................. Iv i �l k�PHOy� PHONE %� /(lC. ....... ..:f............. �ELL DR............................................................................ . . ...... .................... ...............................................AD ESJa o.............................................................. ............. ............. .................. .:................................ G .i <br /> PHONE PHONE Z „ r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details No. `� c <br /> New Building No. Bedrooms ...."7. <br /> ....x.. Type of nstruction: -- � <br /> Addition /�^"�- Septic Tank Size Gals. .......... <br /> Sanitary ...x.... Size .:3..1:'.:••ft. x ..> -.��.... ft. `r.. <br /> Filling/Grading .„•„•,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> Mobile Home Slope .......................................... O <br /> Privy .......... 3. Use (describe exactly,'I -famil Perc. Rate ................................... <br /> Dry Well '• ' <br /> Well .......... home,garage, motel, etc.) """”" <br /> Subdivision .......... <br /> Seepage Trench z <br /> .................................................... .......... <br /> Camping Unit Privy <br /> Seepage Bed <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 located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. �`1fi,1 - `„—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : 1 o <br /> ______________________________________________________________________ I i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... :M <br /> ,q0 K €r <br /> New <br /> "h � • I a <br /> b <br /> G <br /> Y O1 <br /> m <br /> 31tn v (n r D uo W 1p <br /> ry c d d A c c <br /> LQ . m <br /> Lb, mac — am nay <br /> p1cw > > 3 <br /> D� � <br /> u•� yd ' <br /> o c m <br /> to <br /> . ....................................................... ...................................... r' <br /> 0 <br /> C_ <br /> m <br /> ...... ........... <br /> Signature o wner or Agent Datec c <br /> Remarks <br /> m •• r: H <br /> N <br /> O <br /> Inspection Date ....................................... % ...................... N N O V <br /> Zonin A ministrafor ) S g 8 <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 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 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 />