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C ?2 C�12p; <br /> Burnett County Office of Zoning Administrator Ln - o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT g' 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < ,n <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use A c \ :�r <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n <br /> .d......Se6.................................................. .................................................... N °v <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ADDRESS <br /> . 5. ...,....W.�S:.............. ........... ............................................................................................ <br /> ADDRESS ADDRESS <br /> .. �1 <br /> `.... ..- X5....3. ............................... ............................................................................................ <br /> ... <br /> PHONE .................................... PHONE <br /> ........... . i <br /> ..... ............ . ............................................................................ <br /> PLUMBER WELL DRILLER ' <br /> ......W..e.(as: ...r......t..w t <br /> ..................................... ............................................................................................ <br /> ADDRESS . ADDRESS V <br /> 6.W. ©. . 0 <br /> ............. ............................................................................................ o <br /> PHONE PHONE Z <br /> DESCRIPTION <br /> 4. Sanitary Facilities: ' ° 0 o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o <br /> New Building .......... Type of Construction: No. Bedrooms .......... :\� m <br /> Addition Se is T�nk,Size Gals. .......... <br /> r 'Q '• <br /> Sanitar <br /> ...�... Size .............. ft. x .............. ft. <br /> Pilling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... 0 r o i <br /> Mobile Home .......... Slope .......................................... � <br /> Privy .......... 3. Use (describe exactly�j farruLfamJ+' Fare. Rate ................................... 3 <br /> Well .......... home,garage, motel, etc.) Dry Well .......... F tr <br /> Subdivision Seepage Trench .......... : ` '• <br /> .... <br /> Camping Unit .......... ................................ :............... Privy .......... M <br /> . .. ............... Seepage Bed .......... �6 Z <br /> ---------------------------------------------------------------------- y <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road p h <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- n a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING °T <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o o <br /> 5. Lot Size: Fig. A. 6. Location: <br /> c •• <br /> ................ ft. x .............. ft. — ............................... sq.ft. .............................................................................., <br /> e <br /> o � <br /> N ` p <br /> rj-'tcill <br /> O <br /> s <br /> T °q�Y <br /> hU <br /> � Z <br /> :r <br /> .r <br /> M n r 9 m � Z <br /> r01 Q 7 N 7 F <br /> M. vNi a C�` m m <br /> m <br /> Z 00' 0 asm <br /> o n ' 70 <br /> Ul _ m <br /> :Wo <br /> i iVt�o [ m <br /> .... :........................ ..... ......... ........................... !o!?....��.1........................ :C o C <br /> Signature of Owner or Agentt, Date <br /> Remarksa2inz...��P...Y.... T x : In <br /> v <br /> .................................................................................................... .. . ................. .. <br /> •II <br /> C <br /> {: . . . . . N <br /> Inspection Date ..., ..a3..C�...-0....r�........ ..,7. ' 2. � ....Zc.i....... .... ............ � o rix o m <br /> . .. ......... <br /> Zoning A inistrator x.J...•........ 8 8 8 8 8 9u) <br /> NOTE: A preliminary site inspection must bg made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case ofsewerage 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 Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> _)Mrd /-Z4,ait Zl �// /G 94 Vfe9G <br />