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Burnett County Office of Zoning Administrator <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 located as '� o <br /> in <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 pQ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a x <br /> 0--r, (Z 4�''..� E Jr3rJNfN �� <br /> ...................................................................... <br /> M <br /> A <br /> OWNER Ip�le`ase print) / CONTRACTOR or SURVEYOR or AGENT m '" <br /> NL.t ........................ ....... ..................................................................................ADDRESS ADDRESS <br /> ....MN:...�..�_. ................ .............. S........... <br /> . ..... <br /> . ...... ............ .... ..... <br /> ......................ADDRESSQADDRESS <br /> a°a; <br /> g� <br /> ........................................................................................... <br /> PHONE . .......................................................................................... <br /> PHONE <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... "A'D' R....ES. ............................................................................... _� <br /> ADDRESS DS <br /> o 0 <br /> n o <br /> . . .................................................................... . .......................................................................................... <br /> PHONE PHONE � <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details • • <br /> 0 <br /> New Building Type of Construction: No. Bedrooms z <br /> Addition .. ✓ .„.1-�4,R-role. Septic Tank Size Gals. <br /> �. : <br /> Sanitary .......... Size ..- ..... ft. x ...�•... ..... ft. .......... <br /> FillingiGrading ,,,,,,,,•, Height......,..;.. Stories .....�......... 4a. Absorption Field Site: <br /> n <br /> Moving .......... Area .......J�.'.b.. .©.. "�.:......... Soil Type .................................... r <br /> Mobile Home ......... Slope .......................................... .. <br /> 0 <br /> Privy ...,...... 3. Use (describe exactly, 1 -family Perc. Rate ................................. . <br /> Well home,garage, motel, etc.) Dry Well .......... <br /> subdivision ,..,,..... Seepage Trench .......... (p <br /> .................................................... l0 <br /> Camping Unit - Privy r <br /> .......... ...I...... <br /> -- -------------- ---------- ------- Seepage Bed-------- i <br /> N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc, should be sketched in Pig_ A- Include road f� & <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter I a <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING -� 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — QJ o <br /> ________________________________ ______________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ...�.Y..G...... ft. ft. — ............................... sq. ft. <br /> .............................................................................. O <br /> U) <br /> on <br /> ON O <br /> H <br /> 0 <br /> 7� <br /> i'CV-V� c � <br /> / : <br /> c I D <br /> T <br /> Z <br /> O <br /> M <br /> mN a a = a <br /> too un < m m c •9 <br /> Z 0O a'u. � D n m <br /> O �� oro <br /> � o � <br /> m <br /> ........ ....Z..-1.: ..-�� .�..... p <br /> Signature of Owner or Agent Date �° C <br /> X <br /> Remarks m m <br /> ........................................................................................................................................................................................ 'sa — <br /> II <br /> - O <br /> Inspection Date ....................................... .... . ... . T�-C14.11.5� ........ .. ............. u, 0 0 <br /> . . . ��CC m <br /> Zoning Ad MfnistratorITL [ 8 $ o o N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faclll <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 be made without approval of the Zoning Administratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />