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2PI?L%o'1�TL�O: <br /> Burnett Zounty Office of Zoning Administri for Iv <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3' <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 1 M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the m (}L <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 y„9 <br /> regulations of the <br /> S/tpto of Wisconsin. <br /> ./..Y.........w x.../../ .1'1.......1 a••L•c1S.fm.!1L4S...��'SAr. .......................................... ...... <br /> OWN (please print) CONTRACTOR or SURVE R or AGENT <br /> _ r w <br /> ./....... �.fl>/ ........A..U/." ..................................................................................... ...... a <br /> ADORES ADDRESS m <br /> �` .........�1>/./.. 5........ `�/F .................................................................................... ...... :O <br /> ADDRE ADDRESS I <br /> ............... .. ...... . .......... ..y................... ............................................................................... <br /> PHONE PHONE ° V I <br /> ........................................................................................... .................................................................................... ....... <br /> PLUMBER WELL DRILLER <br /> p : T <br /> ADDRESS ADDRESS 0 G <br /> ........................................................................................... .. <br /> P.. . ........................................................................ ....... O w ry <br /> PHONE HONE...... .. P « r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathro ,s .. ....... i c <br /> New Building Type o nstruction: No. Bed oms .. ....... <br /> Addition Septi ank Size Gals. .. ....... h C <br /> ... ........... .......... <br /> /L/ .. . ft. <br /> SanitarySize .......... ... ft. x ... ; <br /> Filling/Grading .......... Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area . . . Soil Type ......,,:................... ....... o <br /> ................................. . . ... 'tri <br /> Mobile Home .......... Slope ........ ........................ ....... <br /> 1Uh <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Ra ' <br /> Well ho ,garage, motel,etc.) Dry W 1 .. ....... <br /> . ........ <br /> �' y.� See ge Trench 0 <br /> Subdivision .......... fff,,,Uo �,Jy� •• ••••••• o 5 <br /> Camping Unit .......... 6 !q( ,Le-�v P y <br /> 1......../i L�.......Q.. . .............. Seepage Bed w ' <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. Ac <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local ed at <br /> n <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. f <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ :�; 0 <br /> ___ __________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ... C�.t. sq.ft. ...................................................................... ........ 1 <br /> ! i <br /> 0 <br /> �kc <br /> O i <br /> 140Lkn,v� ( fi <br /> c <br /> ----- <br /> mNn nm nn9 <br /> tom : � m a ,n' m' 3 <br /> m a <br /> » a : n <br /> o c =- m <br /> ............................... x no : m <br /> 2 ' : p <br /> ... .. ...................................... c C <br /> Signature of any or Agents Date c <br /> /// ....... `� '7. ...... n <br /> Remarks ........ . . .0.!1(.��.. . s>a+f G.......... ......... u�.a7v;:`<...../" eJ.�t:ti:. .........lf..!��:`.`.o./.�r`��:............. .... <br /> ................................................................................................................................................................................... .... <br /> 0 <br /> Inspection Date .. . .... ... ... P' 'r v' N m <br /> .... m <br /> ..................... . <br /> Zoning A inistrator <br /> NOTE: A preliminary site inspection must be made and s' approval granted on all structures involving sanitary facilities before construct n <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app)cation 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 beel issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or ipecifications 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 />