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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described�nd p M ;qj <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 Ordin nces and the laws �antl 3 <br /> regulations of the State of Wisconsin. 3' a <br /> c _ <br /> K ... .... :i. e .... ro 1�,,�......... , <br /> cc... .. _ ........................ q5............... <br /> OWNER <br /> t) CONTPAqTOR or <br /> GENT <br /> .f..`L•J1.JM... .................... .....W J..t SURVEYOR Or A.... <br /> ..l.1Qq-..1................ . d <br /> �, Ro o <br /> .... a i <br /> AD S _ ADDRESS <br /> Q� ................................................................................. ...... _ U� <br /> ADDRESSADDRESS <br /> ......................................................................... I <br /> PHONE PHONE <br /> I.......WEL...L...DRILL.R'*i'L ..ER................................................................ ...... <br /> PLUMBER <br /> ........................................................................................... . ..... .. ........................................—............................`...... 'O <br /> ADDRESS AD.. DRES.. ..S ` 'm •C) <br /> PIT- <br /> 0 < <br /> . . . ................................................................................... . . ......................................... ................................ ...... „�o' ,» <br /> PHONE PHONE...... .. Z , r <br /> DESCRIPTION 4. SanitaryFacilities: P o <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> ( n <br /> N"Building Bedrooms <br /> 9 .......... Type of Construction: ••'�•""' � I <br /> Addition .......... Tank Size Gals. ... ...... <br /> .................................................... •t <br /> Sanitary .......... Size ..........4... ft. x .............. ft. ...�...... <br /> Filling/Grading ,....-..., Height............. Stories ............... 4a. Absorption Field Site: . <br /> Moving Area Soil Type .............................�...... .Q <br /> Mobile Home .......... Slope ................................... ...... <br /> Privy .... ..... 3. Use (describe exactly -family Parc. Rate ............................ ...... m <br /> 'o <br /> Weil ,. . ., home,garage, motel,etc.) Dry Well .......... m E <br /> Seepage Trench z <br /> Subdivision . ..... •••I•••••'• o <br /> Camping Unit Privy .......... {} <br /> .................................................... Y. <br /> Seepage Bed ...... .. .00 <br /> -------------------------------------------------------------------�-- : 1 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. o- <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at o. <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. `— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ o <br /> ----------------------------------------------------- --- <br /> 5. Lot Size: Fig. A. 6. Location -------------- <br /> ................ ft. x .............. ft. — ............................... sq.ft. • - .......i....... <br /> tdchecpm D <br /> " I O J <br /> J <br /> i � <br /> 1 D3 <br /> Yo I paq c o <br /> 0 <br /> b <br /> J <br /> Z <br /> � a <br /> �n <br /> J m <br /> f•' D tD IPS <br /> on > n = c m <br /> m Z <br /> Zu, m p <br /> O o m D 1 <br /> J ct a <br /> M <br /> c C <br /> O m 9 <br /> A <br /> M <br /> Signature of Owner or Agent Date <br /> T: tl <br /> Remarks ............................................................................................................................................ <br /> N <br /> .......................................................................................................... .... .................... .... ... ... .. .. . <br /> W m <br /> N D N + N m <br /> Inspection Date ....................................... ..�....... .. W.... .. u, (l. N O O U1 m <br /> ..... .. .... . . . .... g . . . <br /> Zonin Administrat 8 8 0 8 8 8 rn <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 appli ation 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 beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APF(ROVED. <br />