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rj#49P9 40 00d 1-'0000 was xAI <br /> Burnett County Office of Zoning Administrator o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o Q <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 m C ?� <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> 3oa ERS <br /> . a <br /> ...:........ .... .. ..17L•`.P.S....:..['.:T......................... ......... . . . . ........................................................................ H :s <br /> O ER (please print) CONTRACTOR or SURVEYOR or AGENT m <br /> m <br /> N.fi.....a�............t�u.+t...�.!t.r...Y. ............................................................................................ <br /> AD <br /> R E S S / ADDRESS <br /> ....... ................................................................................... .ADD.... ...R..ES... ...... <br /> ............... <br /> ..... <br /> ........ <br /> ....... <br /> ........ <br /> ......... <br /> .................... <br /> — <br /> ADDRESS S <br /> .......rt+.............7.../..10.......................................... <br /> PHQWF <br /> -!.......................................... PHONE <br /> .... .. .... . . ............. ..................................................................—....................... <br /> PLU BER WELL DRILLER <br /> ........................................................................................... ............................................................................................ <br /> NO O <br /> ADDRESS ADDRESS <br /> n p <br /> ............ <br /> ............. . ...................................................................... ................................................................................ -' �. <br /> PHONE PHONE C' Z o h- sG� <br /> DESCRIPTION 4. Sanitary Facilities: / o o <br /> 1. Work: 2. New Building Details No. Bathrooms ....... � <br /> New Building .......... Type of Constsu�tion: No. Bedrooms ...' .. <br /> Addition .......... ......... ,,.X:l..S .1.. ____., Septic Tank Size Gals. <br /> �........... d: <br /> Sanitary .. . Size .............. ft. x .............. ft. . ..�� <br /> Filling4a. Absorption Field Site: <br /> .......... Height............. Stories ............... p <br /> Moving .......... Area ....................... Soil Type .................................... <br /> . ................. <br /> Grading Slope ........................._............... <br /> T <br /> o <br /> .......... <br /> ? i <br /> Mobile Home Pere. Rate ............................ ...... <br /> 3. Use (describe exactly 1,-famil <br /> Dry Well '�" i�,l, <br /> Privy ,......... home,garage, motel, etc.) +-,- <br /> WellSeepage Trench .......... <br /> .......... .................................................... <br /> Subdivision ...,.,,.,, Privyb <br /> .................................................... <br /> ___ Seepage Bed <br /> -------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road ✓� ° e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- _a :M <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING O i( < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. N <br /> -' <br /> ------------------------------------ ---------------------- ---------- '� <br /> 5. :t SizeFig. A. 6. Location: <br /> �+Q v p <br /> J.d..C'...... ft. x .yQ.Q.... ft - ............................... s9.ft. <br /> T 0 <br /> C <br /> N O <br /> O T = <br /> 0 <br /> p <br /> 0 <br /> z <br /> A L o <br /> yf "eDj <br /> d <br /> :V <br /> J N r no W Z <br /> c a o+ <br /> - - n <br /> Z 00 `0 ' 1 � f07J <br /> O = — <br /> b4 <br /> O1 <br /> .. ............... ..................................... ........�....5..... ...... p <br /> Signature of Owner or g nt Date <br /> o i C <br /> ................................................................................................................... X M <br /> Remarks .�. ?s....�i..�.�`.'E.'�'_ T m <br /> v <br /> Us . <br /> p ; <br /> ......................................................................................................................................................................................... <br /> 1 ,so <br /> Inspection Date ............a..:�..�.�....... m <br /> L.V. �5..:.. e?2:rr'............................................... 0 0 0 0 0 c�'it <br /> Zoning Administrator o cacacacacacn <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 revoker) if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans of 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 />