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tty Office of Zoning Administrator v 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> 3 3 <br /> � " o <br /> . !H,- CONING ADMINISTRATOR The undersigned hereby makes application for a Permit for the work described and located as < — <br /> nown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ! ................................................................................. a O <br /> J..4 . .�?..w t t.q.....�,.k ..s.............. .......... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a m <br /> . .. .y...k-", ..........)....)...... .-....... ............................................................................................ <br /> ADDRESS ADDRESS <br /> . .......................................................................................... <br /> ADDRESS ADDRESS <br /> � a1 11 �1 <br /> PHONE PHONE <br /> ........................................................................................... .WE... ...LL DR........I.. ...LLE.. R.. .. . ... ...... ....... .... ... .... . ..... ........... -{--�' <br /> PLUMBER . .. .. . .. ... .. ... . .... : i i -7�\� <br /> o Y \ <br /> ADDRESS............................................................................ RS <br /> .ADDES ............................................................................ n, O <br /> n o <br /> ........................................................................................... .....-D E. �Z O .i <br /> PHONE PHONE <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 0 <br /> 1. Work: No. Bathrooms -O <br /> 2. New Building Details • ••• o <br /> New Building ...,, Tyye of Construction: No. Bedrooms .......... i <br /> Addition .,,..,,,.. ... .q .. G - Septic Tank Size Gals. .......... i <br /> Sanitary .......... Size .....Z..y... ft. x ....W.A.- ft. i �: <br /> Absorption Field Site: i Absorpp <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. <br /> Moving .......... Area ........................................... Soil Type .................................... r E <br /> o <br /> Mobile Home .......... Slope .......................................... <br /> Per <br /> Privy ,,,,,..,,, 3. Use (describe exactly, 7 -family c a e Wrench <br /> W Ni i <br /> Well .......... home, garage, motel, etc.) y .•••.. <br /> Seek\ <br /> Subdivision .......... Seepage <br /> .. ................................................. <br /> Camping Unit Privy .......... t i <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well,sewage systems, roads, etc., should be, sketched In Fig A. Include road n <br /> D <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway Inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Q o' <br /> ------------------------------ --------_---- <br /> 5. Lot Size: 9 1< -� Fi 6. .... o\ C S q <br /> p <br /> .�.(.�..�..... ft. x .a�. ..l..a�. ft. — ............................... sq. ft.t. <br /> n <br /> /O N o <br /> o � <br /> H' <br /> O <br /> n <br /> a <br /> l <br /> m <br /> j r tr z <br /> 7 10 (1T <br /> 04�U <br /> C d M <br /> F <br /> N O: C m n <br /> D = <br /> Z 0 o n <br /> O a <br /> SCUM C.. set <br /> b....U.............................. S-, c <br /> S,A) � n <br /> Si nature of Owner or Agent Date - <br /> X ] <br /> marks -r' n <br /> ...............................................................................................................................................................:......... .� E <br /> m <br /> ......................................................................................................................................... ... .......... <br /> ... ...... <br /> ......v .. .... <br /> Inspection Date ....................................... �'!•l. nin ator ogg <br /> Adminlstr . . . . .Ci <br /> n <br /> / / H <br /> gooco <br /> NOTE: A preliminary site inspection trust 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 riot 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 Adm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />