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Burnett County Office of Zoning Administratoro 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3. <br /> — <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located Use <br /> ` u, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use a, <br /> Ordu-ince, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 ac <br /> Ol..f/.?.f�`:!G./"5.....e......... �:C%.:al?..................... ............................................................................................ '\S' <br /> (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> f � <br /> 4�.CJ.......... l.�J.l.b.Ea.... U......�............... . .......................................................................................... d h' <br /> A�D �SADDRESS 'Rc. ..2<. .... .... ?:Z.r2.:...........:.`.?` .:`./.c�..3 ............................................................................................ �DRESS ADDRESS \ i <br /> ..................................................................... ...............................................................f..........� ... ....... :� <br /> PH.................. PHONE I <br /> n1 i <br /> Jam....., .... ... .............................................................. .........................................................j......: .. . ....... <br /> PLUMBER WELL DRILLER <br /> ................ <br /> ........................................................................................... . .......................................................... . <br /> ADDRESS ADDRESS n o !'1 <br /> ........................................................................................... . .....XF....................................... .....,.�..G.y�r. O .± <br /> PHONE PHONE i J \ Z r <br /> DESCRIPTION 4. Sanitary <br /> Facilities: <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details """ p o <br /> New Building .......... Type of Construcymn: No. Bedrooms ....�.- � <br /> Addition /" • Septic Tank Size Gals. ...... ... �` <br /> - .5....A.3................ <br /> Sanitary Size .............. ft. x .............. ft. '�"� <br /> "' 4a. Absorption Field Site: i� ' <br /> Fillingl Grading .......... Height.............Stories ............... i <br /> Soil Type .................................... r i <br /> Moving .......... Area ........................... ............... V o <br /> Mobile HomeSlope .......................................... <br /> .......... <br /> Privy .......... 3. Use (describe exac -family Pere. Rate ................................... iso iq ' <br /> Well .......... home,garage, motel, c.) Dr Well .......... (v <br /> subdivisionSeepage Trench <br /> .......... .......... % � i <br /> .................................................... Privy � <br /> Camping Unit .......... .................... <br /> ................................ Seepage Bed <br /> ______--___ ______________________ .G <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched In Fig. A. Include road � A Q ?� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- i7 a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING o� m <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> _-------- f.. <br /> 5. Lot Size: Fig. A. 6. Location: y <br /> cc <br /> J. �:...... ft. x .1...1.0 ft. — ............................... sq. ft. <br /> ............................................................................... G <br /> 0 <br /> LGfi� ron <br /> Ito <br /> — -- N s' <br /> -- -- <br /> i <br /> r <br /> -- <br /> __ N <br /> di <br /> Yt CSS 71 <br /> � a <br /> o <br /> a <br /> m <br /> T y Z <br /> m CT n £ <br /> N � � — mm <br /> O V G y <br /> Z 03 n <br /> O 7 n n 3 <br /> fAs a — _ <br /> O 1 <br /> In <br /> Signature of 0 net or Agent Date <br /> / � l X <br /> Remarks .... ..�1�..✓ D.._ !:ZL`.Ghc • p <br /> .......................................................................................................... m <br /> v <br /> ............................ .tT:<t. . :-.... ..:<. Et �—.............. .. ............ . ....................................................... T <br /> dr- <br /> Inspection Date ...ra..S.. ...... ...... ....... ................ . `c 8 o $ g m <br /> Z ing Administrator $ o o N <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 />