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Burnett County Office of Zoning Administri for �' c <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 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <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 Wisconsin. » _ <br /> .:. 1.�a�In.tf�...H.:...Ke <br /> q .l6 se•I ........................................................... ...... <br /> ... <br /> OWNER (please gnnri^^n I / CONTRACTOR or SURVEYOR or AGENT � p <br /> !...11 �..... ...ta.P.. � ( ' ..................................................................................... ...... 'a L <br /> AD DR SS ADDRESS <br /> ADDRESS .... .................. <br /> S.. �... ........... ........ ADDRESS..................................................................... ...... ( iG <br /> a.............................................. Y <br /> PHONEPHONE......................................................................... ...... OO . <br /> ..................hohe............................................................ . ... . `o .e................................................... ...... `m <br /> PLUMBER WELL DRILLER <br /> ADDRESS . .ADD.. R.....ES....S....................................................................... ...... � <br /> n 0 <br /> PHONE PHONE...... <br /> .................. <br /> .......... <br /> ....... ........................ <br /> ........ ...... � 3 .i <br /> DESCRIPTION 4. SanitaryFacilities: ° o °" :5; <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... i o ip <br /> New BuildingNo. Bedrooms <br /> ... ...... Typ f Construction: ... • ••• <br /> Addition ..X.... ,,,-,• ( Septic Tank Size Gals. ... ...... - <br /> ............................. < <br /> Sanitary .......... Size ....A ft. x .....!.(P.... ft. ... ...... <br /> Filling/Grading .....•...• Height...I'z�... Sto ies ....!..... . 4a. Absorption Field Site: i <br /> Moving .......... Area ....... 2s{ Soil Type ............................. . <br /> ........... ................... ..... <br /> Mobile Home .......... Slope ................................... ...... .. <br /> o i <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............................ ...... <br /> Well .......... home,garage,mo el, etc 1 Dry Well ... .... . <br /> Subdivision „-•,,,,, �...... � Seepage Trench ... ...... <br /> Z <br /> Q.(.G�. ........... o <br /> Camping Unit Privy ,.. ...... (�5 <br /> .................................................... yz . <br /> Seepage Bed . . <br /> --- — — — <br /> ---------------------- ---- — ------------ ..... ? i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. <br /> c <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 intersects n. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. a' <br /> — ____________________________________________________ __ -- <br /> 5. Lot Siz�gg: qq I Fig. A. 6. Location: <br /> .. ... ft. x ....J..I...... ft. <br /> — ..((�'.�. $Y sq. ft. ........................................................................ ...... E <br /> IC-�G'4.C]t :_jam <br /> _ 40 0 <br /> � v <br /> 0 <br /> .e�L f <br /> N <br /> > <br /> r <br /> T W <br /> �a <br /> Z <br /> 1_ A <br /> 1b1 <br /> � it ID I 0 rc2, 000CC <br /> T. <br /> r 1f(C1�1_I(VT (iK In <br /> 9 6:5. . CN J J ; <br /> O rAo D� 1 <br /> 92, <br /> hill <br /> lthrc,er �-o�Ke "- °c <br /> 3/Z-q ....... x n : n <br /> .... ............. ............ ......... _ P <br /> M <br /> Signature of Owner or Age Dat <br /> Remarks <br /> T: m <br /> m •• <br /> o . g <br /> ......................................................................................................... .... .......................... ... . .......i ....... o <br /> 0 <br /> . ... ...... <br /> Inspection Date ....................................... N o m <br /> Jhf1C?�..... .......... .. m <br /> Zoning Administrator 88 $ $ co <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applic ition 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 been i ssued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans ors ecifications 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 />