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Burnett County Office of Zoning Administrator ICY, <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the rk described and located as <br /> shown herein, The undersigned agrees that all work shall be done in accordance with he requireme is of he Burnett County Land Use c :� <br /> Ordinance, Sanitation Code, and,with all other applicable Cou;,/Or,A <br /> dinan es and a laws and r gula ons of the State of Wisconsin. 3 a <br /> ........✓..�../..�.v.... .�..C.'..jo............................................ ... . . . ..�},/��.f.5. . :..:�2.1 i <br /> OWNER (please print) A oR" r SUR E or AC IT a <br /> 7�.�........(.. ...... !:... .................. ;' ? ..........,/ '���c.%..>................................_ a • <br /> ADDRESS FESSlye....f.F...�V 'L /iT'� '. ......4.rte' '�1/ J..f................................. - `r <br /> ADDRESS ADDRESq/ <br /> 2 <br /> ............... ili'.. YS <br /> PHONE 'Frio <br /> .......... �\ <br /> PLUMBER WELL DRI LLER E' <br /> ..... . . . ............................................................................... . . ...... . ..................................................................... �.......... p : <br /> G� <br /> ADDRESS ADDRESS ;R <br /> n0 O <br /> < <br /> ............. . . ...................................................................... .......'N-E................................................................................ o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: <br /> 2No. Bathrooms <br /> . New Building Details •..• •. o (� Q <br /> New Building . Type of Construction: No. Bedrooms .......... Li r <br /> Addition •.,,,,.... Septic Tank Size Gals. .......... <br /> .................. ,,,.... ...................... <br /> Sanitary .......... Size ..... ft. x ...3.�!..... ft. - i <br /> Runngl Grading .......... Height.r�......... Stories ....C......... 4a. Absorption Field Site: <br /> Moving Area ......... Soil Type .................................... r i <br /> Mobile Home <br /> Privy ,,,,,,,,,, 3. Use (describe exactly, 1 -family Slope .......................................... <br /> .......... i <br /> Pere. Rate ................................... i <br /> Well .,,.,...,, home,garage, motel, etc.) Dry Well .......... <br /> 1 <br /> Subdivision <br /> ........ <br /> See..... . .. page Trench .......... <br /> . ' <br /> i .i. .......... .. . . ..... <br /> Camping Unit ......... Privy .......... .�-. <br /> Seepage Bed ......... <br /> IJ <br /> ------------------ --------- ------------------------- -�. .N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc , should be sketched In Fig. A. Include road ! e <br /> Q <br /> setback, side and back yard dimension and location and setback from all bodies of wafer. It property Is located at a highway inter- a � <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> --_--_-------------------- --------------------------------------------- c <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> / µ <br /> N <br /> ZZ <br /> _ . <br /> iO <br /> 7v/ to 0 T <br /> fir- o <br /> d <br /> i <br /> JJ C � W Y <br /> n < m c m <br /> � o. _ F <br /> m NO: C : m G ID <br /> Z O p . D a <br /> 0 <br /> Z(147m <br /> C <br /> 'Sign e of Owner or Agent Date <br /> o C <br /> X <br /> 70 <br /> arks ......................................................................................................................................................................... -c m <br /> ° O <br /> a9 <br /> ........................................................................................................................................................................................ .A, n <br /> .......................................................................................................... ....................... \ . <br /> .............. . o <br /> Inspection Date ....................................... . .�J'FLL�f....:..... ............. ... 't� N N n`^, m <br /> uNo ovm <br /> Zoning Admini trator FV 8 0 0 8 0 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 perrnit 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 />