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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and iS2� <br /> located as shown herein. The undersigned agrees that all work shallbe <br /> bb)e done ' acc r nce with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and er applic ble o ty rdinan s and the laws and <br /> reg'j a�t Ions of the State Qf W�iscon in. � f � � • <br /> OW R I lw pri t \ I RA j0 r SU V R or AGENT J <br /> .....5^.�.��...... .... . ..115....... .. ,............................... ............ ................. ....— ................ <br /> AD ESS c I A R SS I m i <br /> �r..nJ�..II . .. I�.... .337............... ..pa . Q.. ......... ....` ................................... ...... V : <br /> ADDRESS / ADD <br /> .:.. .�5 ................................1....... : I 1 <br /> PHONE PHONE <br /> PLUMBER............................................................................ .WELL DRILLER....................................................... <br /> ..... . . . ............................................ —............................... . .ADDR...... ...................................................................... ....... •� . <br /> ADDRESS ES....S r'p .0 <br /> PHONE PHONE Z <br /> DESCRIPTION4. Sanitary Facilities: P o S <br /> 1. Work: 2.T��gws Buil in Detail No. Bathrooms i•••.••• s <br /> New BuildingC` f ns ructio No. Bedrooms .. ....... M _ <br /> Addition `.. ......, Septic Tank Size Gals. ....... i <br /> Sanitary .......... Size � .. ft. x .... ... . ft. ..�....... i i <br /> Filling Grading .......... Height ...... Storie e,,..... <br /> 4a. Absorption Field Site: <br /> Moving .......... Area ..�.p Soil Type ............................1....... i .o <br /> Mobile Home !/. .. Slope ..................................`....... J. ' .. <br /> .......... <br /> Privy 3Vhe.d <br /> ribe BxactIV '1 •family Perc. Rate ................... 0 <br /> ^ Dry Well <br /> m tel tc.) m <br /> Well ,,,,,,,,,, r8 ± Seepage Trench aSubdivision ...I...... U <br /> ..... ...... Privy ._ <br /> --Cemping Unit— .......... ..k....... <br /> Seepage Bed S� <br /> ------------------------------------------------------------ ' I y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched In FI . A. ;,�� .g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property Is loca ed at �\ <br /> a highway Intersection, show the Intersecting highways and the setbacks required along them and at the intersec Ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : o' r <br /> ---------------------------------------------------- ' 1 <br /> --yyy— ---- <br /> S. Lot Size: Fig. A. 6. Location: / KD................ ft. x .............. ft. — ............................... sq.ft. .............. .. Ate.... ....... .L....... (J1 <br /> N C <br /> G <br /> :( � N <br /> z <br /> M I II P <br /> I S <br /> on <br /> I <br /> (P -U r/1 m -V <br /> \ eKysX Z FL M <br /> aN: w m <br /> I P N2 <br /> S : <br /> I."`( - : m <br /> '�Q�ature of Owner or Agente <br /> mi w <br /> Remarks ................................................................................................................................................................... <br /> l..... <br /> .................................................................................................. .................. a ....... . . : 8 <br /> �f 'n,,�,it Q� <br /> ator <br /> Inspection Date ....................................... Y .. '. ! (Y.�,�, C7 `J Q'n "No' 1mn <br /> NOTE: A preliminary site Inspection must be made and site approval ranted on allStructuresStrlucudres Involving sanitary fa ctlon At y <br /> p y p pp g p y ilitles before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be Issued. Do not purchase or install a septic tank,do any plumbing or start any bullding until a permlt has been Issued. A permit may be <br /> revoked If misrepresentation of any of the information conveyed herewith Is found to exist. Changes in plans or speclfications shall not be <br /> made without approval of the Zoning Administrator, <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />