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Burnett County Office of Zoning Administra or �' /� <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• — <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd # M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he n ££ -- <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of Wisconsin d <br /> ....... is <br /> ....a��,.: . iJ.�:..�...L..0 .� .t.i....... II . ...... . . . . . . . .................................................................. ..... _, _. 4?p <br /> OWNER (Dleese print) CONTRACTOR or SURVEYOR or AGENT •� <br /> ... \:4^.-: :...{..>...............i'..'.......................................... . .................................................................................... ..... ear i l� <br /> ' ...g ADDRESS <br /> ��, — <br /> ADORES l •••. <br /> Lu........... ..::'. .:. L........................ . .................................................................................... . <br /> ADDRESS ADDRESS <br /> ........................................................................................... . .................................................................................... ..... ; <br /> PHONE PHONE - <br /> ........................................................................................... WEE"L..L D....RI.. L...... ............................................................ ...... : 1- <br /> PLUMBER LER.... • <br /> .......................................................... .AD......RES.. .... ....................................................................... ...... <br /> ADDRESS DS 0 o <br /> ct < _ <br /> ........................................................................................... . ............................................................................. ...... ? <br /> PHONE PHO.....NE Z » r _ <br /> DESCRIPTION 4. Sanitary Facilities: ° c <br /> v <br /> 1. Work: 2. New BuildingDetails No. Bathrooms ... ...... 'o <br /> No. Bedrooms ... ...... i <br /> New Building Type of Construction: j.? i <br /> Addition Septic Tank Size Gals. ... ...... <br /> Sanitary .......... Size .............. ft. x .............. ft. ... ...... i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: '• <br /> Moving .......... Area ......................................... Soil Type ............................. ...... r- <br /> o <br /> Mobile HomeSlope ................................... ...... <br /> .......... y <br /> Privy .......... 3. Use (describe exactly,*1 •family Perc. Rate ............................ ...... ; <br /> Well .......... home,garage, motel,etc.) Dry Well ... ...... - <br /> Seepage Trench o <br /> Subdivision ...........................................I........ .... <br /> Camping Unit Privy .. ... <br /> .................................................... Seepage Bed . . � i <br /> ----------------------------------------- ------------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft( . 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 intersec on. -- „<-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq.ft. ...................................................................... ........ <br /> k <br /> o � <br /> 0 0 <br /> 0 <br /> r :'J 1 <br /> Z Er <br /> 0 <br /> 9 <br /> v <br /> a <br /> m <br /> Z <br /> i <br /> m (n m rm > co cm -0 <br /> n «ro < > 00 - - nt <br /> m �n•c - nm naS <br /> o < c <br /> Oro m <br /> 2_O D 1 <br /> � r�j,J Win ' <br /> n : <br /> $ .� m <br /> moo : <br /> 4� ) <br /> Xo " y <br /> K lv;n i m <br /> ................................. ............ ......... .. ..... <br /> Signature of Owner or gent , Date $ <br /> ) . { <br /> Remarks ....�....�..... ...�... ......... . :. ....:. . ...j.�.:.J. . ... ............. ....... .. . ... . ... . .. . .... ..... <br /> w: <br /> .................................................................................................................................................................._............. ...... <br /> o . o <br /> o . c <br /> ....................... . .............. ...... <br /> Irn <br /> InspectionDate ....................................... ... %::.....:.............:............,.r......:...��'r.............. ..... � o ' � n1 <br /> Zoning Admi istratdr $ $ $ $ fA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cilities 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 be n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />