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Burnett Count/ Office of Zoning Administrator <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 C <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 applicable County Ordinances and the laws and <br /> regulations of the State of WisconsinCIL kA <br /> . <br /> .�D1. .....1�:....So.� .; <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ...p?..- C <br /> � 3...5Z16.N.>)!Z�I�G��.... c! ................ . . . . . ................................................................................. a ;:Cy <br /> ADDRESS ADDRESS m 1 \ . <br /> !..`/........................... ............................................................................................ <br /> ADDRESS ADDRESS v1 <br /> ........................................................................................... ............................................................................................ 1 :; •� <br /> PHONE PHONE <br /> o fJ..... .. ... . �t .. R( <br /> ....... Q .... .......................................... ..... .................. 1 <br /> .................................................................... <br /> PLUMBER WELL DRILLER <br /> .... .. ............. v <br /> ADDRESS ADDRESS mC) <br /> L C n O <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: o ° <br /> 1. Work: No. Bathrooms <br /> ��// 2. New Building Details ^^ e <br /> New Building .....A.. Type of Construction: No. Bedrooms ...':?.5... <br /> Addition ........ ...... ... . .n�?A+??� Septic Tank Size Gals. 7. <br /> . .. - •� <br /> Sanitary <br /> ,,,.,X... Size ....9%... ft. x ...�4;.j. ft. E i <br /> Filling/Grading ,,,,,,,,,, Height....... .. Stories ...../........ 4a. Absorption Field Site: "! . <br /> g ....L/... :.Q............. Soil Type .................. .o <br /> Moven .......... Area .............. <br /> Mobile Home .......... Slope ............................Jt..-.�..P.... 71 .. <br /> Privy .......... 3. Use (describe exactly, Perc. Rate ....................:�:.`......... <br /> a. <br /> Well Tiome garage, motel, etc.) Dry Well .......... m <br /> Subdivision ,,,,,,,,,, Seepage Trench .......... o <br /> .................................................... . <br /> Camping Unit Privy <br /> .......... .................................................... .r........r .,^� <br /> Seepage Bed <br /> ----- fB.Y..?3. <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. ;..0 cAl <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at 11 <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 'P :A `„— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ______________________ <br /> 5. Lot Sizef: ! sq.f A. 6. Location: a <br /> .r.0 ....... ft. x ..�00... ft. — ........�.t'.1�. .0 L(7L•Itr CR/f� Q09>) 76 <br /> ..................... ......................................................... � <br /> sf� t :VAQ-o4 1 sLr��.tcs2 :tom <br /> It uIZV V2(P4 (vv tc ()rm1pa � <br /> n <br /> N O <br /> O <br /> _O <br /> O <br /> 0 <br /> 0 <br /> � N <br /> S " o <br /> 911A114Cf D2w.tf�' <br /> �f <br /> M (n MU) DtD W <br /> M. tae — O. (pan � <br /> O tl O m m <br /> O fn O D � —I <br /> u N a <br /> 0 o S <br /> o c' = m <br /> c ; <br /> ......... 7 <br /> K f <br /> Sign ture of Owner or Agent lei' Date o <br /> m: u <br /> Remarks <br /> ...................................................................................................................................................................................... <br /> N ' O <br /> O . 0 <br /> O ' O <br /> . ....................................................................................................................... 9 ........... . . j $ <br /> .tion Date ....... ,'!/� <br /> ................................ ....21-7 ...:��"(Q `onin AdministratA preliminary site inspection must be made and siteapprovrall structures involving sanitary facilities before construction <br /> gin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> ,d. 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 Mss <br /> ` misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be "ill <br /> ,ut approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />