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Burnett County Office of Zoning Administrator o c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> y<...... !r ltSf ............... .................... <........................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a ;% <br /> .�...r , .............. ............................................................................................ <br /> ADDRESS /Ax/ <br /> �J ADDRESS ?� r <br /> !�.. /....[. t�i. 7`..�7.. ............................................................................................ <br /> y./Ax �k1 <br /> ADDRESS ADDRESS <br /> �2...-..93�3...-. .S.:1.�..�.......................... . .......................................................................................... �o <br /> PHONE PHONE <br /> / <br /> T.... ... <br /> ..................... <br /> ...... .... .... <br /> ........................................................................................... . . . .......... . .. . .......................... :� :� :� <br /> PLUMBER WELL ORI LLE -4i <br /> ..... . . . ............................................................................... �l p <br /> ADDRESS ADDRESS � � o <br /> ........................................................................................... . . . . ..PHONE................................................................................. Z O .i : T <br /> PHONE � r- <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° :H t <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details ••.. •"" o ' <br /> New Building ...... Type of Construction: No. Bedrooms ....7..... <br /> ' » <br /> Addition ....X... .... 17L7A/. Septic Tank Size Gals. <br /> ....................../..�......... < <br /> Sanitary ...R.... Size .....a.... ft. x ...../.U... ft. 1 <br /> Filling/Grading .......... Height c? Stories ....../........ 4a. Absorption Field Site: i <br /> Moving .......... Area ....... ;F7........ Soil Type .................................... <br /> Mobile Home K Slope .......................................... <br /> Privy ••........ 3. Use (describe exact) , 1 -family Parc. Rate ................................... <br /> Well .......... home,garage, motel, c. Dry Well .......... G <br /> Subdivision .......... ........................................ Seepage Trench Privy .......... � <br /> Camping Unit " or <br /> SeepageBed �.. .---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Include road [ <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- p o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. c'� o <br /> --------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: I�n <br /> ................ ft. x .............. ft. . ............................... sq.ft. . ................................................ ............................ <br /> A/K r:', M€ N <br /> f n <br /> N O <br /> o ' 1 <br /> O <br /> 1111 'k o <br /> l a <br /> 22 3Z �gTyRf1'X� <br /> /N = <br /> ter <br /> i <br /> I� (Nn- I <br /> •ur OO Z� <br /> '�o2u d d <br /> = hoaa m � sf <br /> o g? ° ' ami <br /> Signature of Owner or Agent <�� Date ;Yt.X <br /> Remarks .C'. ,-'G, .. ...G: Z.:`.t a......:........................J...................................................................................... 0 <br /> m m <br /> ............................................ . <2'..."i� ...% ............................................................... e <br /> ^ll <br /> ............................................................................................................... .. ....... ...�tratcrr <br /> 'o Ute - - wm <br /> Inspection Date -/4—.... .... .................... ...... . ..... . `3: o . ? m <br /> -. ........................ <br /> Z 8 8 88 8 rn <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 We made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />