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_may? C 6-t9yl J. <br /> Burnett County Office of Zoning Administrator W M 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 )4 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < c <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> Leo i^ n l NI11 I I N 5. ..L.. ............................................................... <br /> o <br /> f <br /> .............................................. ............................................ a <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> l..R.S..9....N......!oT!^.. . T..:....M.!!v....r....A,L ..... ...................................................................... <br /> ADDRESS ZIDDRESS m <br /> ".JAJ <br /> �.. ............. a�?. .�I. ' �'.... ... ........................................................................................ �J io <br /> ADDRESS ADDRESS <br /> ^,.. <br /> i5..'...3.fi.�....". �SI ........................ .................... <br /> .................................................................. <br /> ................................. <br /> PHONE vE <br /> // E <br /> ............ ..t?.!.. ............................................................ . .......................................................................................... <br /> PLUMBER WELL DRILLER <br /> O <br /> D .................................................................................. m L7 <br /> ........................................................................................... .A. ''D'*DDRESS n o i+ <br /> ADDRESS <br /> . ...................................................................... ............ . ..................................................... <br /> .. ................ . PHONE......................... . Z r �� <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: r <br /> o <br /> Bathrooms <br /> 0.....G... ^ <br /> 1. Work: 2. New Building Details No. 3 o <br /> Bedrooms .... <br /> No. .SS.•. <br /> New Building r�'. onstruction: -b <br /> r7,f- Septic Tank Size Gals. ...0..... F <br /> Addition ........T„I�.Q..m...�............ ........ Ire < <br /> Sanitary Size .....d....y.. ft. x ”' """ <br /> .......... ....a.. .. ft. <br /> Z' 4a. Absorption Field Site: A: <br /> Filling/Gratling Height............. Stories .....I......... : <br /> Soil Type .................................... 1F: r <br /> Moving Area o <br /> Mobile Home .......... Slope .......................................... <br /> Privy Perc. Rate ................................... f <br /> .......... 3. Use (describe exactly, 1 -family <br /> Dry Well <br /> Well ........., <br /> ho garage,garage, motel, etc.) y r <br /> l3 Seepage Trench .......... a, N <br /> Subdivision .......... .........A:.....q... V....................... <br /> R.... Privy <br /> Camping Unit .......... .................................................... � <br /> Seepage Bed ......... o <br /> ------ ------------- H ti Z <br /> sewage, <br /> wellsystems, roads,etc., should be sketched in Fig. A. Include road a :r <br /> Location of proposed structures and existing structures, g Y 1. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway Inter- o �. <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING (5 N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ' <br /> -------------------------------------------------- ------------------- :0) <br /> 5. Lot Size: Fig. A. 6. Location: m <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> n <br /> IN O <br /> 3 <br /> 3 <br /> I � � p <br /> LO <br /> Y <br /> a%: v T <br /> Lv <br /> r, o Z <br /> F <br /> c° r <br /> S� <br /> N r om o).2 <br /> �p c <br /> m R1 <br /> Z o o n 77 <br /> off' o <br /> wo z <br /> rr <br /> G <br /> : c <br /> Signaure of Owner or Agent Date X rS <br /> T rr <br /> Remarks ......................................................................................................................................................................... r, C <br /> m <br /> (se ' <br /> ........................................................................................................................................................................................ II <br /> .. ........ . ...................................... <br /> 1 : <br /> NR <br /> Inspection Date ....................................... .. .. ...... ....... ..........g.... . rrini itra.......................... <br /> Zonin ministrator � � 8 8 8 8 $ S v <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, rlo 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 />