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( f_ 'y)• l <br /> F <br /> Burnett County Office of Zoning Administrator fC - <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> '- 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. <br /> r� c �.........tz. 'Yi ..................... ............................................................................................ n <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT :04 it <br /> C ..7........ ilE(Z4/}►v ...... d <br /> ..................................... ............................................................................................ <br /> ADDRESS ADDRESS ' <br /> .... ................aKlvc�� r tzp�� <br /> NDRESS C�f..�4f J%J h/!1! <br /> ttilof� 7`.�o!f�fc.......... ........... I^ l� <br /> PHONE PHONE ?rT <br /> .. . . . ................................................................................. I :N <br /> ............................................ <br /> PLUMBER WE LL DRILLER..................�..�..�..v............................... . <br /> Q�1 S.^......../.T.. .�:..... •O icy_,, <br /> ........................................................................................... . . . . r N <br /> ADDRESS ADDRESS m Ll <br /> n o :A <br /> O w <br /> », c <br /> ........................................................................................... . . ................................................................................ <br /> PHONE PHONE........ .. Z � r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o rp <br /> New eulldingType of Construction: No. Bedrooms .......... <br /> Addition ,,, Septic Tank Size Gals. .......... <br /> y <br /> Sanitary ..l%... Size .............. f ........ <br /> Filling/Grading .......... � •, 4a. Absorption Field Site: <br /> .......... Height Stories ............. <br /> Moving .......... Area ........................................... Soil Type .............................. ..... .^:a'1 ro i <br /> Mobile Home Slope .......................................... <br /> .......... .o <br /> d <br /> Privy ,,,,,,,,., 3. Use (describe exactly,'1 •family erc. Rate ............................... ... � .S <br /> Well Dr.,,,,,,,,, home,garage, motel,etc.) yWell ••• ••••• <br /> Z <br /> Subdivision .......... .................................................... Seepage Trench .......... ' <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed —I p <br /> --- — — -- ----------------------------------- —a x <br /> -- _ — — --- — — :� � <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 back yard 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. f t o <br /> 5. Lot Size: Fig. A. 6. Location: ` <br /> ..... ft. x .............. ft. . ..... EC!P E <br /> IN it <br /> :A <br /> f 4_a <br /> I <br /> I <br /> c <br /> G <br /> A � A <br /> X50 <br /> V< m in mlAr Dm W <br /> rOi tov < > > 0 S. S. m <br /> 4 m. �n•c — am nag <br /> o wo •2 0 Q0 � <br /> D1 <br /> o 2 m <br /> � 0 <br /> R. ........9................................... ...................................... <br /> Si nature.. Owner or A ent Date <br /> Remarks <br /> o : <br /> ................... <br /> g $ <br /> m <br /> Inspection Date ...1... .. ./..�.......�.x....... ....... .. .'�.............'"2`"f�•—................................. � c."n � o o N m <br /> toning Administrator 8 8 8 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site approval granted 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 />