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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� + <br /> e5j <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 3 <br /> regulations of the State of Wisconsin. » u a <br /> .........N.ei.l..I`7UJI. .S.................................................... ........................................................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ........... _..1..anx...J 623............................................ ............................................................................................ <br /> ADDRESS ADDRESS .. :Z <br /> Hxtds.an.,...W1..59.Q1.6........................................ `H' <br /> ADDRESS ADDRESS <br /> ...................................................................... .P..H.. . .................................................................................. P. <br /> :o <br /> PHONE ONE.. .. <br /> :nt <br /> ..............Donald...Daraie.Ls............................................ ..... . . . . . UQ ins <br /> PLUMBER WELL DRILLER <br /> &ox...y}.;..Siran.,...W.b..5.487.2......................... . . . . . ................................................................................. C) <br /> ADDRESS ADDRESS o L1 <br /> 715-349-5533 < <br /> ............................................................................ P <br /> ......... <br /> HONE................................................................................... Z r <br /> N <br /> PHONE 0 <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ....l :— e <br /> New Building .V.... Type of Construction: No. Bedrooms ....z.... <br /> Addition „ Septic Tank Size Gals. ..7.50.. <br /> ,,,, <br /> Sanitary •.•••• ••• <br /> , .... Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> o <br /> Mobile Home .......... Slope .......................................... ^ <br /> Privy .......... 3. Use (describe exactly,'1 -family <br /> Perc. Rate ................................... d i <br /> Well ,......,,, home,garage,motel,etc.) Dry Well .......... T- i <br /> Seepage Trench z <br /> subdlvialon .......... .....1...family..home................ .......... o <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed .... <br /> X.... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A­ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at «` g <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. :1� „<—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> i <br /> __ <br /> 5. Lot Size: Fig. A. 6. Location: ( <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> Cy �' <br /> N O <br /> O <br /> J <br /> :N <br /> � M <br /> F <br /> 77 <br /> 6 <br /> v <br /> �1 w <br /> :Z <br /> m <br /> Z <br /> O <br /> v <br /> e <br /> m <br /> :r <br /> D CA71NrD W W -V <br /> m. Na�< -' nm aa70 <br /> o < d C y > > ic <br /> O ep 0] <br /> O HO D ' <br /> o c ^ m <br /> 0 . D <br /> m......................................................................... r, <br /> ................. T o <br /> Signature of Owner or Agent Date o <br /> u <br /> ........................................................................................................... . <br /> Inspection Date ....................................... L, Lz:+Live.�..!..�.....Zt: /1,(.C, ;���� . rano' o a m <br /> Zoning Admini trator• ) 8 8 8 8 8 in <br /> NOTE: A preliminary site inspection must be made and site appioval 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 /> t' <br />