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Burnett County Office of Zoning Administ ator r 7 -g4 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' 36. <br /> 3 j <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and �2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements f the ,$ t <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and thand 3 `d <br /> regulations of the State of Wisconsin. e law <br /> ...........fes. . �... a <br /> OWNER (Plane <br /> print) .... .................. .............................. . . . <br /> CONTRACTOR or SURVEYOR or AGENT <br /> ...75��..�..�... .��... . �:1............�.�/.1/.:�'r. a <br /> ADDRESS - ....................................................................... ........... ........ <br /> /y� n/ ADDRESSm ?' 't <br /> ADDRESS J...!e(./.:'.;.......:5'���5_ � \ i <br /> ... ................................................................................ . <br /> ADDRESS """ <br /> PHONE :. ........................... . .................................................................................. . ^ <br /> """ <br /> PHONE 'c"Q. <br /> ... . <br /> PLUMBER . ........... . .. . ............................................................ <br /> WELL DRILLER "" <br /> ........................................................................................... <br /> ADDRESS . . ....... O _� <br /> ADDRESS........................................................... ...................... 6'I g�- <br /> ............. . . . ...................................................... O <br /> PHONE .................................................................................... ....... <br /> < `Q <br /> .• ' ............... PHONE :� y� <br /> DESCRIPTION z r <br /> 4. Sanitary Facilities: P g o — <br /> 1. Work: 2. New Building Details No. Bathrooms „ ..,.,,, v <br /> New Bu11GIn0 o <br /> Addition " Ty�pqe�of Construction. No. Bedrooms .. ,,,,... R <br /> .......... r�•`�"�.•F�e.Y.d..`... ..... Septic Tank Size Gals. .... 3 •'�(� <br /> ..... .. ... <br /> Sanitary Size ...,/..ems, ft. x ... ...... ft. '• <br /> FiIIInplGratlinp 4a. Absorption...... ... Height..f.�....... Stories .... ...... ... Field Site: <br /> Moving Area Soil Type ............................. .... . <br /> Mobile Home Slope o <br /> .......... ................................... ...... .� <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ............................ . m ' <br /> .... <br /> Well home,garage, motel te.i Dry Well <br /> .......... ... ...... <br /> Subdivision Seepage Trench z <br /> Camping Unit .. .. ... p�L ... O . <br /> .......... ...`� 1.4ari,. .. Privy ... ...... .�� <br /> ------------------------ Seepage Bed ... ..... <br /> -------- ------ ________________ __ : it <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc. should be sketched in Fig A. rn <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is localc d at g <br /> —� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. . <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. `�'�•: '5. <br /> ^ <br /> _______________________________ _ . \ o <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> p 0. <br /> b <br /> 0 <br /> T <br /> / o <br /> 7J N V rnr� D co 01 -0 0 0 o c c ur <br /> 6 <br /> 9 4•c 6 y C P. <br /> 0 0. <br /> Dm 3 <br /> 2 En <br /> 1 e[� FGFbr1e.' -r L 1 m 0 O <br /> /L(� GLC(., <br /> Signatu f Owner or Agent ..f.... Date '� ""' 1r�In.Q. ole �C-Uf};(� : o <br /> � m <br /> S <br /> Remarks <br /> T : 0 <br /> ........................................................................................................................................................................ <br /> m <br /> ....................................................................................................................................................................................... » : w <br /> o : <br /> $ . g <br /> ? ............ j N <br /> ... . ..... . . <br /> Inspection Date ....................................... �s w <br /> .... . ..... . .lU.K7•'..........:...... . U!:7. ,o�.�. �n m <br /> Zoning Administrat r $��$ <br /> �gryr) 8 8 8 8 (/1 <br /> NOTE: A preliminary site inspection must be made and site aper val grantetl on all structures involving sanitary facilit es before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applical ion 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 is;ued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or spe ifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPRC VED. <br />