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e*'7 , tom'21 I—), <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 Ns <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the Work described and located as F4.1 <br /> sin shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use n <br /> m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n. <br /> - a <br /> a..b......, .R. >..E.R.M..�+ tl� <br /> OWNER (please print) /— CONTRACTOR or SURVEYOR or AGENT `D0 <br /> 33.I.a..L`'1 .v �o.v /ELLS B�.` d a <br /> ....................... ......................... ............................................................................................ d <br /> r� V+ <br /> ADDRESS 14A-hdP r 7 /V ADDRESS <br /> bSo3 � <br /> .............. <br /> ..................................................... ..................... .AD......DRES....................................................................... <br /> ADDRESS S : <br /> �P�.`1..—` .. ..7.— .. . /. ................................. ..... ...................................................................................... <br /> PHONE PHONE .�,• <br /> .......... <br /> ........................................................................................... .WE....L........R.I..LLER................................................................. 1 <br /> PLUMBER L D <br /> O <br /> ............... . ................................................................... . .......................................................................................... <br /> . ....... <br /> ADDRESS ADDRESS n O <br /> .............. <br /> ........................................................................................... . ............................................................................ <br /> PHONE PHONE Z r . <br /> DESCRIPTION 4. Sanitary Facilities: o v o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... {w <br /> New Buildingr No. Bedrooms .......... "f E <br /> „Xi,..., Type of Construction. <br /> Addition <br /> /I't Septic Tank Size Gals. .......... <br /> Addition ..td/.Q..R..Sit....../...�.'.I.*.... ...... <br /> Sanitary Size .,/,.`j!...... ft. x J.5...... ft. <br /> Filling/Grading .......... Height............. Stories ... ......... 4a. Absorption Field Site: ^tel <br /> Soil Type .......................-.......... :: r <br /> Moving .......... Area ............................... o <br /> Mobile Home Slope .......................................... Q <br /> ... ...... i <br /> Perc. Rate ................................... <br /> Privy ..a(..... 3. Use (describe exactly, 1 -family 93 , <br /> home,gora e, motel, etc.) Dry Well <br /> - """"' <br /> Well ..... l <br /> Seepage Trench <br /> Subdivision Sf0 r4-�.2 •-•,.Se.een�f/e� """'•.. <br /> Camping Unit Privy <br /> Seepage Bed ......... <br /> w ' <br /> ----- ----------------------- '� i m f <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road r Q <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property is located at a highway inter- s d <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection_ CLEARLY LABEL EXISTING Uf <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> ----------------------------------------------------------------- <br /> 8 i <br /> 5. Lot Size: o 11. Fig. A. 6. Location: d �.� n E <br /> ......._....... ft. x .............. ft. - .. -1,00............. . ..... sq. ft. .....�.!r.�1...�...�'.c.....-?..Y.../..�../�...A:L!................ <br /> (n <br /> �O n <br /> N OA o' <br /> vl <br /> -E <br /> >� o <br /> 7�I <br /> el) � <br /> r T c <br /> Z <br /> ry 7ir.y e r3 <br /> cpb,`n <br /> VI r < y m Z <br /> n a < <br /> N a C ' rnm <br /> a 70 <br /> N1 I 0 <br /> 0 <br /> ......................................._......... ... rd............... o <br /> Signature of Ow er or Agent Date <br /> .�G�SI l f / rto bP l�S�..... T x v <br /> Remarks ...... .......... ........!!!....................... f.............s. .S.I�..................................................P'I ................ <br /> (�.......�G:/-ef N d���\ .S�/•w .....Stitt�t......'. <br /> � n <br /> ............................................................................................................. ................ ................. :� <br /> v� "_ 1° U <br /> Inspection Date ....................................... ..... .... .... . ........ ..... a 0 0 <br /> T <br /> Zonin dministrator g <br /> NOTE: A preliminary site inspection must tie made and site approval granted on all structures Involving sanitary acihties <br /> before construction can begin. In the case of sewerage disposal systerns, 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 plumhing or start any bUdd- <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 of specifications shall not be made without approval of the Zoning Adm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />