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Burnett County Office of Zoning Administrator �' 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 i�(� <br /> located as shown herein. The undersigned agrees that all work shall be done in actor ce with the requirements of the ,$ c -j�,1 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other appli ble C un O dinance and the laws and 3 N <br /> re ulation of the t f Wisconsin. I Q. <br /> ... ................................ .�1. ....................... <br /> OWse Print) O ACTOR or SURVEYOR or AGENT <br /> ... .R....L....a....(...,.c...�........N.....I. .. . S • ' .a" "" . .......................'o...... <br /> ESS <br /> .•�......................... ...............* 1....................... <br /> ...... . . . .... g•'•"'.oaf . <br /> ADDRESS ADDR SSd <br /> ✓� <br /> .1.?,...... {. 1..-.2a �...................... ............................................................................................ o� <br /> PHONE PHONE <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . ......................................................................................... Q <br /> ADDRESS A..DDRESS m 0 <br /> o <br /> c r/ <br /> ........... <br /> ........................................................................................... . ........................................................................ <br /> PHONE PHON........E 0 0 iF'� <br /> DESCRIPTION Xed <br /> ry Facilities: ° o .'/��J <br /> 1. Work: 2. New Building Details throoms .......... c <br /> New Building .......... T Cons uc ' n: drooms .......... <br /> Addition Y ,,,,,,,,,,, ank Size S. .......... < <br /> Sanitary ./,`... Size .............. ft. x ... ft. .......... <br /> ........... <br /> Filling/Grading ,,,,,,,,,, Height...... SEOJIe 4aption i Site:..Moving .......... Area ype ... .................. .........Mobile Home ..... ........ ... ...............Privy .......... 3. Use (describe exactly,'1 -family R e ........... ................well .......... e,ga age,motel, et II ..........subdivision .....Q.yS. e Trench ................ ......P g ..........Cam In Unit .......... ....... .... s Q( e Bed . ........ <br /> -------------------------- ________________----_-____ - <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at "' 4 a <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. ` <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ' <br /> 5. Lot Size: Fig. A. 6. ca io /' <br /> ................ ft. x .............. ft. — ......... .. sq.ft. .o.. .. .l .E'J. .— h-- <br /> ................. .. ..� t <br /> ,pa 1� _ <br /> N O <br /> O 7 <br /> 7 _ <br /> o110 <br /> q <br /> ` v <br /> 9 m v m r D m m <br /> T. Na•`c -' nm aEL <br /> a : y <br /> 1c/tfn <br /> -� ............ —• O V P O <br /> �/! [4� a c S <br /> ` yt. - . .. .7..... .. � x � A : � O <br /> Signature of Owner or)0;CDate <br /> r o <br /> Re ark t/..e.v.f�.1!5r. ..... <br /> See s........... $�e�w�,. ............ .. ................................. ............. .. <br /> V <br /> 0 <br /> ..... . ................................................ o <br /> N O N n <br /> N <br /> Inspection Date ....................................... ..... ........... �' N N N O m <br /> ............... g ........................................ $ $ goIn <br /> Zonin dm inistrator o (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before constructio <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 building until a permit 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 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 APPROVED. <br />