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Burnett County Office of Zoning Administra or <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT15 3• 30 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ind <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he ,$ c � <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of WisconslCIL <br /> ��... ..:�i 1..+z ..................................... ....... <br /> OWNER (pluprint) CONTRACTOR or SURVEYOR or AGENT <br /> ..... }:....1........ .................................................. ................................... ..... a . <br /> ADDRESS / sy893 <br /> ADDRESS I ` <br /> W.. j..w....... <br /> ADDRESS ADDRESS <br /> ........................................................................... ..................................................................................... ...... <br /> 1 <br /> PHON PHONE <br /> k0c— X350 <br /> .. . ...... ............................................................................... ............................................................... ...... <br /> PLUMBER f WELL DRILLER i <br /> ........................................................................................... .A.....DRES............................ <br /> ................................................... ...... <br /> ADDRESS DS <br /> ct <br /> C < <br /> ......... ................................................................................. . ............................................ ................................ ...... w <br /> PHONE PHO......NE Z H r• <br /> DESCRIPTION 4. SanitaryFacilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ... c <br /> New BuildingT No. Bedrooms <br /> ... ..... ype nstruction: """"' i <br /> Addition /j •........... ./ Septic Tank Size Gals. ... ...... <br /> Sanitary .......... Size ......�,Y.r ft. x ......... ft. ... ...... . <br /> Filling/Grading ,,,,,,,,,, Height..../.�.01'.. . Srtr��ries ....�......... 4a. Absorption Field Site: ; <br /> Moving .......... Area .......`.7.�5�'.'':........... .......... Soil Type ............................. ...... i r i <br /> o <br /> Mobile Home .......... Slope ................................... ...... .. <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............................ ...... <br /> Well ,,.• . . . Dry Well <br /> .........Subdivision Seepage Trench ... ...... o <br /> ...,,,,, _ <br /> ; <br /> Camping Unit . w�...:-...� .... Privy ... ...... .n e <br /> Seepage Bed .... <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 local d at ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. r <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> -------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> I <br /> ................ ft. x .............. ft. . ............................... sq. ft. ....................................................................... ....... <br /> N O <br /> O � J <br /> J <br /> WOgp I}OVriC s VI v <br /> � O 'C <br /> Z <br /> O <br /> p •� -rO <br /> ��e d <br /> n wo- < JoEL — m <br /> M �a� aeo nam <br /> oo<_ : dC0J � ; <br /> O N O m D <br /> P N J y a A <br /> o a ' <br /> � 0 D <br /> m � <br /> ................ U t�. bb x A . O <br /> . ...... .......... . ...0,�............... . <br /> 9 P <br /> Signature of Owner br ant Date $ <br /> m <br /> Remarks m a <br /> o . o <br /> b o <br /> .. ..... .... o <br /> - J NNJlNm <br /> Ins Date <br /> Zoning Aministra ca <br /> NOTEApreliminar site inspection must be made and site approval granted on allstructures involving sanitary facilities before <br /> construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl cation 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 beei i issued. A permit may be <br /> revoked it misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 5pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />