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Burnett County Office of Zoning Administrator LLA, 7 c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3, <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ 12 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the Stat_eI of Wisconsin. ex <br /> 3 <br /> . ..................................... ........................................................................................ n - <br /> OWNER olleas(e�JQ,,ri_ot�).�j CONTRACTOR or SURVEYOR or AGENT <br /> .1+ ....A\.l7.lAA-.4.r......................... ........................... . ...... . . ............................................................................... a <br /> ADDRESSI ADDRESS — ^1 <br /> 1.�...l .y... ...� . 7� i I <br /> ADD ESS ADDRESS <br /> ''^^ <br /> Q1II ....................................................... . .......................................................................................... <br /> ...... ..�.1 ... <br /> PHPNE PHONE <br /> ....Sou.b..n .......................................... ............................................................................................ 4 <br /> i <br /> PL BER WELL DRILLER `,. <br /> ADDRESS .. 00 <br /> .. . ............................................................................................ _ <br /> ADDRESS <br /> L3'57.3.-.240................................................... . . . . ........................................ ..Y....................................... 0 <br /> PHONE PHONE N <br /> DESCRIPTION 4. Sanitar Facilities: P o V <br /> 1. Work: 2. New Building Details No. Bathrooms v <br /> New Building No. Bedrooms <br /> .......... ype of Construction: .... <br /> Addition „ ,.,. Septic Tank Size Gals. (.Q.Q.0 ;� <br /> ......................... ....................... .. <br /> Sanitary .. ... Size .............. ft. x .............. ft. .......... ,� <br /> FIIIIngfGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil TYPe .................................... r <br /> Mobile Home Slope O ' <br /> Privy Perc. Rate ................................... m <br /> .......... 3. Use (describe exactly, 1 -family <br /> Well .......,,, home,garage, motel,etc.) Dry Well .......... m i <br /> subdivisionSeepage Trench ....... z <br /> .......... .................................................... ... o <br /> Camping Unit ......... Privy .. .... .. <br /> .................................................... <br /> Seepage Bed <br /> ..x.. _ . <br /> ___________________________________________________________________ : 1 .N Q <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 backyard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------- >� <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... ' <br /> Q <br /> n <br /> O <br /> 0 <br /> 0 <br /> 0 <br /> J [ Z Z <br /> 0 <br /> D <br /> a <br /> X invmracoco -V <br /> n "v < > > o c c m <br /> n - <br /> m. "ate - am as S <br /> oo< ; dcyoo3 <br /> o ina m 0 D� 1 <br /> e, <br /> EL y <br /> o c m <br /> O <br /> � 0 <br /> C <br /> S : : A <br /> L <br /> ......................................................... m <br /> Signature of Owner or Agent Date o ; : C <br /> Remarks C ' : o <br /> T u ' <br /> ,......L..,..:a'...�<F..::,.......`.............................................................................................................................. <br /> .......................................................................................................... <br /> P : $ <br /> Inspection Date .C .`� .7... .��. .... Zg <br /> moning Administrator $ $ $ yNOTE: A preliminary site inspection must be made and site approvanted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />