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Burnett County Office of Zoning Administrator d '� 0 0 <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 located as < h o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 0 c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n V� <br /> — _ <br /> 4� ................................................... <br /> .... ..................... '....... . /h.......................................... d nj <br /> OWNER (please print) C TRACTOR SURVEYOR or AGENT <br /> . .................... a <br /> ADDRESS ADDRESS ,. <br /> ... �....;...all......a.:.Y. 9............................ <br /> ADDRESSADDRESS •• • NN <br /> PHONE................................................................................ .PHONE........................................................... . <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER n <br /> O <br /> ADDRESS ADDRESS <br /> . . .................................................................... . ..................................................... — o <br /> PHONE PHONE ? 17 <br /> DESCRIPTION4. SanitaryFacilities: ° o - <br /> 1. Work: 2. New Building Details No. Bathrooms 10I <br /> New Building No. Bedrooms O <br /> .......... Type of Construction: m <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... < i <br /> Sanitary .......... Size .............. ft. x ft. <br /> Filling/Grading „ ,,•,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ..... Soil Type .................................... <br /> ........ . ........................................... 7�1 <br /> oMobile Home ..... Slope .......................... ............... <br /> E <br /> 1 <br /> Privy .......... 3. Use (describe exactly, 1 -family Pend. Rate ................................... .S, E <br /> Well ••...•.... home,garage, motel, etc.) Dry Well .......... ) i <br /> Subdivision ... Seea e Trench <br /> .................................................... Privy <br /> Camping Unit .......... .......... 9J <br /> .................................................... <br /> ----- -------------------------- Seepage Bed .......... --- Ea <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road l <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- j _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEZ <br /> L EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> -------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> �c ,eel �2S/�)) G <br /> 0 <br /> N o <br /> a <br /> T <br /> m q <br /> Z <br /> 0 <br /> t <br /> 7J rnr v :E nrm z <br /> on <br /> m a a c = m n m <br /> 6 0 oD a m <br /> 0 O n � � <br /> 0 <br /> G . N m <br /> ........t'u.r..............................t. ............................ /,,,`................ �.o C <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ................................................................................................................................... <br /> m <br /> ........................................................................................................................................................................................ rfl <br /> 41 <br /> ...................................................................................................... .. ................. ......... .... ....... ............................. 'U•t” <br /> Inspection Date ....................................... . ....?'L!4 ? Q� ^' u U m <br /> .............. ... ...... . . . . .. �.J........... u o 0 <br /> Zoning Admir- trator $ $ $ $ $ $ Cmn <br /> NOTE: A preliminary site inspection must be made and 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 any 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />