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611 <br /> 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 < — � <br /> shown herein. The undersigned agrees the! all work shall be done in accordance with the requirements of the Burnett County Land Use m c h� <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a FW1 1 <br /> N � <br /> OWN (please print) C RACTOR or SURVEYOR or AGENT M <br /> ..�.. ........................................... . �k St,f. ....1 f.... 1g�3........................ a <br /> AD ESS ADDRESS <br /> ADDRESS ............... . ......................... <br /> ....... <br /> ...... <br /> ........ <br /> ...... <br /> ....... <br /> ....... <br /> ..................... <br /> ... � <br /> ADDRESS <br /> ........................................................................................... .PHON..E.............. <br /> ........ <br /> ... <br /> . ...................................................... � �.. <br /> PHONE <br /> PLUMBER 'W"'E" ..................................................................................... <br /> WELL DRILLER <br /> .....................................................................-................. ......... 'E'S' ............. <br /> ADDRESS .. ................................................................ _ C) <br /> ADDRESS �� <br /> ........................................................................................... . . . . .................................................................................... v, <br /> PHONE PHONE Z O <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building .......... Type of Construction: No. Bedrooms .......... z <br /> Addition ...,,..... Septic Tank Size Gals. <br /> .................................................... .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. -....... <br /> Fillingt Grading ...,.,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ......... .r <br /> ........................................... ........................... <br /> Mobile Home .......... Slope .......................................... .» <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... yL <br /> well ,.,.,,,,,, home,garage, motel, etc.) Dry Well .......... - �- <br /> Subdivision ,` .................................................... Seepage Trench ...... ... �)J <br /> Camping Unit ......,,,, Privy <br /> .......... I i <br /> Seepage Bed ....— <br /> ----------------------------------------------------- � NRS <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road a�\ <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- T °- <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------- ------------------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. - ............................... sq. ft. ¢J <br /> A � CpmN <br /> N C� � o <br /> o � — <br /> Yol . es 173 — /75— <br /> o <br /> - X10 <br /> t 7. <br /> N <br /> � o <br /> v <br /> L� <br /> 7b <br /> r < u m <br /> N2 <br /> < ec <br /> = m <br /> Z — n m <br /> 0 0 nae 77 <br /> o m <br /> ........................................................................... ...................................... <br /> C <br /> Signature of Owner or Agent Date O C <br /> X 70 <br /> Remarks ......................................................................................................................................................................... T m <br /> J v <br /> ........................................................................................................................................................................................ 0 -- <br /> ...................................................................................................... ... ........ ....... .. ......................... TI <br /> v� W <br /> Inspection Date ....................................... Vl N o o m <br /> :........ �u cra. m <br /> oning Administ a r $ $ $ $ $ $ N <br /> NOTE: A preliminary site inspection must be made and It <br /> approval granted on all structures involving sanitary far.11itios <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />