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Office of Zoning Administrator 3 --i <br /> 0 <br /> Burnett County <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> < <br /> = o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 13 <br /> H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use n n J <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 O <br /> a <br /> L� �....................... . .......................................................................................... m <br /> y� /1 ( <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> /yJ1.....4. . :... .......5.�....................................... . .......................................................................................... <br /> ADDRESS ADDRESS <br /> ............... <br /> r. ..•..''.......... .�.:s..............s y.8 .ADDR.........ES...S............................................................... { J <br /> [t1JD RE5S , <br /> ............................................................................................ <br /> .......................................................... <br /> ................................. PHONE ; <br /> PHONE <br /> ...... ...... ..:3..a. <br /> .......................... . ... <br /> ....................................................................................... <br /> 7.. ... 5.......... p Y �. <br /> { 3. <br /> PLUMBER WELL DRILLER _ <br /> O <br /> .. ...... .............................................................................. m Lg <br /> ........................................................................................... .AD.DRES..S <br /> ADDRESS <br /> . . .. .. .. . ..... . .......... . ..................................................... <br /> ........... <br /> ........ <br /> . . . . ........ ..... . .... ..... ....... .......... <br /> 0 <br /> PHONE PHONE (�Z » o <br /> DESCRIPTION 4. Sanitary Facilities: ° <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> No. Bedrooms <br /> New Building ..,?.�.... Type of Construction: Septic Tank Size Gals. <br /> Addition .......... <br /> Size .. ..... .......... <br /> Sanitary .......... / .. ft. x ../... .. ft. <br /> FillinglGrading4a. Absorption Field Site: <br /> .,,,,,,,,. Height 1.�0...... Stories ..... .... <br /> ...... ...... .......... ro <br /> Moving Area . � . .................. Soil Type ............ <br /> Slope .......................................... <br /> Mobile Home .......... <br /> Pero. Rate ................................... w <br /> Privy ...)5... 3. Use (describe exactly, 1 -family Dry Well <br /> Well ..,,...... home,garage, motel, etc.) <br /> .f1 Seepage Trench .......... <br /> Subdivision .......... ..... �,/ -F,�,!t,$.onq, <br /> �........... �v.......... Privy ..,X.... _ <br /> CampingUnit .......... ...............................I.................... Seepage Bed .......... <br /> -------------------------------------------------------------------- RI <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched In Fig- A. Include road � Q <br /> a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I �. <br /> section, show the intersecung highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING ,� a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ° �^ <br /> ---------------------------------------------------- ___-- <br /> 5. Lot Size: Fig. A. 6. Location: �(T{ <br /> 0.0........ ft. xis °P. ft. —�: ��.0.�.9.......... sq.ft. /.....M.�.Imo......b.ar.. '�........S.Trt.it....... <br /> P <br /> N <br /> n <br /> N o <br /> j B O o <br /> 0 <br /> 0 <br /> 0 <br /> �/ f m <br /> a, �' y�af� Jere eYe o <br /> < <br /> m. N 0- , 5 m <br /> ° tP < C c <br /> Vs _ <br /> (? r <br /> 0 <br /> ......��. .... � z , .................... y.-� ..-.... , <br /> G <br /> � o < <br /> Signature o//�� <br /> ff�Owner or Agent Date x <br /> Rennarks/1/6.-/4.... m.i....... .........................1. �...5. x.1.........5. �..i.f...a.f':. -,........ t <br /> . i'c S.s...:r...L..G..t..[X:........ .......<.F.C..Y.......... .......................................................... -- <br /> ✓/ <br /> e.e........... ..Y. . r.. :........:.. .......... . . :: ............. .... ................ <br /> � . <br /> .................sp �.... .. .... �oi inistrator...................... in�san, o o W w <br /> ,tar facil rti m <br /> u <br /> Inspection Date ..................................... ..... . .... 8 0 <br /> of <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures Involving y os <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must lie 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 bulbi <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 he made without approval of the Zoning Administrator <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />