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Burnett County Office of Zoning Adminifli 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 <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. ti <br /> a b <br /> .... Q.!f. ......S.:S'.Q.�F..e n .......................................... ............ . .Q..�. . n tie <br /> ..... ....... ... <br /> OWNER (please print) CONT For SURVE or <br /> ADORERS ..L. ..�....../�l./ ha:. ..`. .....h1:..!:�............ . ...........5... ... .... ...... .. ...... . .... .............. ...... <br /> ........................................................................................... D.............. . .. .... ........................ .... ... .... .... ...... v <br /> ADDRESS DRE <br /> . . ..................................................................................... ... .......... ...... . .... .... .' ..... .. .. .... ...... ...... :1 <br /> PHON PHO >�. .Q <br /> ..................................................... .............. ........................................ ... .. ...... <br /> PLUMBER WELL DRI R :y <br /> IL O <br /> ........................................................................................... <br /> ...ADDRESS................. .. ........................................ ................ ....... _. :O <br /> ADDRESS a <br /> » ; <br /> < ;N <br /> ..... .... .. .................................. ....... O .: <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 1. Work: No. Bathrooms 41 <br /> 2. New Building Details " ""' c <br /> New Building .) Type of Construction: No. Bedrooms .. . ..... <br /> Addition •�rrt m-t Septic Tank Size Gals. .. ....... �� <br /> .......... ......... .11....................................... <br /> Sanitary ..�C..... Size ...A..0... ft. x .... 0. ft. (r.. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ............................ ....... i r <br /> Mobile HomeSlope ................................4. ....... o <br /> .......... Perc. Rate ........................... ....... m i <br /> Privy .......... 3. Use (describe exactly '1 -family R :� <br /> Well home,garage, motel,etc. Dry Well .... m <br /> . ... ; <br /> • Seepage Trench <br /> .................................................... ") <br /> Privy <br /> Camping Unit " """' <br /> Seepage Bed /.. .af "d <br /> ___________________________________________________________________ __ : 1 y R:Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Kr <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _— <br /> ------------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: :d '' <br /> ................ ft. x .............. ft. . ...... sq.ft. ...................................................................... ........ l <br /> O W i <br /> l o ii-I _ <br /> �{7 & (o 1'6-ldare Rd. o nto <br /> /�1 ,1 o ° f <br /> M <br /> 11 (dunl� A 3 (O � <br /> T <br /> -4 z--103 ZN� <br /> PV` � <br /> I'lCl� <br /> �E Jl I' DI:; <br /> 3 qK _ ,i ,,r� L T M HQ U r > M m m <br /> ;AL2 ro - �i:f+ I-- i L`l'�'' 9 c <br /> Z o n <br /> 2 0 m <br /> E� � 0 . O <br /> ... . .... . .. . . •.... . .................................. x A 0 <br /> SignatJre of caner or Agent Date rng <br /> T : N <br /> Remarks ................................................................................................................................................................... ..... m `. <br /> m •• D: <br /> u, <br /> o . o <br /> .................................................................................................................................. .. ..................... .. <br /> Inspection Date ....................................... Uo P m <br /> Zoning Administ ora <br /> ?8 8 8 8 8 8 m <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl cation 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 bee i issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />