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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < in �• :� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M �I <br /> ^' a <br /> r .fold.. .....Q1.s.4.??.................................................. . .......................................................................................... H m w f <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT C <br /> . . . . . ................................................................................. o. <br /> d <br /> ADDRESS ADDRESS `z.m <br /> !}ar.roz�......iZ.......S48.tz........................................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> bb <br /> ......53.Z-5.9.7.1................................................................... . .......................................................................................... <br /> PHONE PHONE $ �� <br /> Donald Daniels �p <br /> ...... .................................................................................... . . ......................................................5...5.......5........5......... <br /> PLUMBER WELL DRILLER <br /> Siren, WI 5+ 872 <br /> :� o :m <br /> ADDRESS . .......................................................................................... :�� n o :0 <br /> ADDRESS <br /> 463-2333...... <br /> �. <br /> ............................................................. .PHON..E........................ <br /> ............... ....................................... ? _ <br /> PHONE <br /> DESCRIPTION 4. SanitaryFacilities: ° o 0 <br /> 1. Work: No. Bathrooms ....1.,.,. <br /> 2. New Building Details <br /> New Building Type of Construction: No. Bedrooms a.... <br /> ° <br /> C :w <br /> Addition .......... .................................................... Septic Tank Size Gals. 7..550.... � �I K <br /> Sanitary ....1C.... Size .............. ft. x .............. ft. .......... ?� <br /> Filling)Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... nE <br /> ....... .. Area .......................................I... o. z <br /> r i <br /> Mobile Home Slope .......................................... 3 :'1 o <br /> .......... <br /> Privy Perc. Rate ..........................2...... <br /> .......... 3. Use (describeexactly, i -family f <br /> Well ......•... home,garage, motel, etc.) Dry Well .......... o iD i <br /> Subdivision ........., Seepage Trench <br /> .......... A <br /> .................................................... :O <br /> Camping Unit .......... Privy ,.. ...... <br /> .................................................... :w <br /> Seepage Bed .X....... o---------------------------------------------------------------------- <br /> .� <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc., should be sketched in Fig A. Include road � ��. C � 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- u :Z a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING i •� < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 5 <br /> -------------------------------------- . <br /> 5. Lot Size: Fig. A. 6. Location: 'v .o <br /> o :m <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... :ro <br /> :.s <br /> N <br /> �d n <br /> a <br /> IN <br /> � : w <br /> vl <br /> vlf <br /> a <br /> a <br /> T : � <br /> N <br /> O <br /> 7J <br /> Xe <br /> O <br /> Z <br /> lAcrii m ' F <br /> Z o�' 0 <br /> O dim nm <br /> . ...................... ..�. .�.. .. .... p <br /> Signature of Owner or Agent Date ° . C <br /> X <br /> Remarks : rn <br /> ......................................................................................................................................................................... C <br /> ........................................................................................................................................................................................ - <br /> ....................................................................................................5555. <br /> .... ...... .. . ....9. ...... ................ ................... <br /> Gt <br /> T5555. .. <br /> Inspection Date ....................................... .. .. ........... .. 5555 . . .: ...................... U '0 8 0 8 m <br /> Zonin�istrator I 8 8 8 8 8 8 N <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, 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />