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C <br /> Burnett County Office of Zoning Administrator a -a z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT '— 3 <br /> d <br /> TO TH'E ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as o G` <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c -1A <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. p. <br /> Laurel Gardin y <br /> O <br /> .......... ................................................................................ . .......................................................................................... <br /> OWNER Iplease print) CONTRACTOR or SURVEYOR or AGENT m �r'� to <br /> 2105 Crestwood Lane <br /> ........................................................................................... .AD....DRESS....................................................................................... a <br /> ADDRESS .d. <br /> Keokuk, IA 52632 `° r' <br /> ..... . ................................................................................... <br /> ADDRESS .ADD.... ...R...ES................................................................................ <br /> S <br /> 'S <br /> PHONE . . .... <br /> ............................................................ .................... � L� <br /> PHONE <br /> Donald Daniels <br /> PLUMBER WELL DRILLER \ P. <br /> ` <br /> Box W Siren, WI 54872 0 <br /> ....................................... ................................................... . . ...... .............................................................................. O <br /> ADDRESS ADD... RES..S C) <br /> n O <br /> 315-?U: ?33.3....................................................... ............................... ..................................PHONE .................... o' <br /> DESCRIPTION <br /> 4. Sanitary Facilities: n o <br /> 1. Work: No. Bathrooms ....1..... °`V v <br /> 2. New Building Details <br /> New Building ......... Type of Construction: No. Bedrooms ;...�...., v? a <br /> b <br /> Addition •,,.,... , Septic 0 F.6� <br /> .................................................... P c Tank Size Gals. .75.... <br /> Sanitary ...X.... Size .............. ft. x ft. .......... �; \ <br /> Fiilingf Grading .......... Height............. Stories ............... 4a. Absorption Field Site: y i <br /> Moving .......... Area Soil T a <br /> YPe .................................... C7 r <br /> ........................................... p <br /> Mobile Home .......... Slope .......................................... :C O <br /> )a ;� <br /> Privy .,...,.,,, 3. Use (describe exactly, 1 family Perc. Rate ............3..................... 'J <br /> ;S <br /> Well .......... home,garage, motel, etc.) Dry Well �' <br /> Subdivision Seepage Trench :t- <br /> .......... ' <br /> o :w <br /> Camping Unit .......... .................................................... Privy <br /> .................................................... <br /> 'tD <br /> .. Seepage Bed ....X.... <br /> ________________________________________________________ _________ < <br /> Location of n to <br /> proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. Include road C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> or <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. a <br /> _____________________________________ o <br /> __ <br /> _____________ i <br /> ____ i <br /> ____________._— . <br /> 5. Lot Size: Fig. A. 6/Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. <br /> ............................................................................... <br /> e <br /> m <br /> n <br /> N 0' <br /> o <br /> _3 <br /> 27 <br /> 0 }4y <br /> � +F•u <br /> O <br /> 0 <br /> T 1M <br /> Z <br /> O <br /> N <br /> m <br /> M N r 0 2 <br /> M tpQn < m c_ 4 <br /> -O (NJl a m m m c <br /> m . <br /> Z o a m <br /> 0-0 a 3 <br /> m <br /> :W v <br /> 7 . -..�6 <br /> Date 0 <br /> Signature of Owner or Agent <br /> X . . . . . . <br /> Remarks ..................................................................................................... m m <br /> ................................................................................. <br /> ...................................................................................................... H : : : <br /> n <br /> ' o: <br /> T <br /> Inspection Date ....................................... �r: U a : : : m <br /> . .................................... <br /> .� .... ...... ......... ................................... <br /> Zoning A inistrator ? 8 8 $ $ S 8 y <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />