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Burnett County Office of Zoning Administrator c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <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. �� <br /> s I�l <br /> .............. ..........c. `.. ../................................................ . . . .............k........°..:.............................................. C <br /> OWNER (plaids,Print) 1 y/��lj! CONTRACTOR or SURVEYOR or AGENT a ;U <br /> 1.(CJ....-? oa.e ....!?.:..:....^.Yf............................... ......... O...e. .` ...�t..-................................................... w '� ir- <br /> ........... i <br /> ADDRESS It 't ADDRESS <br /> l..0..................... <br /> � ...... r3J......................... <br /> . DDRESS ADDRESSa56 :� <br /> -70 <br /> 38a .SZv ............................. . . . .........8t. .. `(03 :'f <br /> PHONE <br /> PHONE ......................................................................... . <br /> ...... ......................................................................................... <br /> PLUMBER WE.. LL DRILLER <br /> ......... . ............................................................................... 'AD'DRE.. S... ...S.............................................................................. <br /> G <br /> ADDRESS ADn <br /> ........................................................................................... . . ......................................... ....................................... .: � <br /> PHONE PHONE...... .. 0 <br /> DESCRIPTION 4. SanitaryFacilities: ° ✓ <br /> No. Bathrooms v <br /> 1. Work: 2. New BuildingDetails """"" 0 <br /> W <br /> New Building Type of 6onstruction: No. Bedrooms .......... ; <br /> Addition ....X... .....1�;?'.....F,ru.�.:�. ...... Septic Tank Size Gals. .......... : �- <br /> ................ <br /> Sari Size ....�.?P., . ft. x ........�... ft. .......... . <br /> Filling/Grading Height..�.r.�/.F.4... St ries ....I......... 4a. Absorption Field Site: <br /> Moving 7. r`.3;. Soil Type .................................... i 0 i <br /> a .......... Area .... .. ... . }......................... o <br /> Mobile Home .......... Slope .......................................... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Dry Well m N <br /> Well .......... home g rage,motel, etc.) """"" - <br /> Seepage Trench o <br /> Subdivision � f ....., """"" <br /> Camping Unit Privy .......... <br /> Seepage Bed .......... <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 ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. N <�- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :V <br /> _____________________ ______________-__ <br /> 5. Lot Size: Fig. A. 6. Locatn: ((,, <br /> I� <br /> ................ ft. x .............. ft. - ............................... sq.ft. ................ . r =Sit w..1 �. c(mf �, <br /> .............................. ... ............................. <br /> 0 3 <br /> J 1C. <br /> / N G o <br /> o <br /> V <br /> 0 V O <br /> N <br /> t <br /> l� <br /> � 0 <br /> Z <br /> O <br /> D <br /> a <br /> m <br /> v <br /> r� <br /> �SQn+ fUT fim mvmrammm <br /> Rem / erg. mNa� '- nmaa9 <br /> - - -- <br /> 4� 7s79- Zoo : � Wo <br /> 111 <br /> o <br /> o <br /> .. A rn <br /> .... ........... . .... .... .....f"'1..............f........... m: AO <br /> Signature oYDwner or Agent Date i l•( t �� o <br /> y , <br /> Remarks ......................................................................................................................................................................... m <br /> ............................................................................................................. ............. N <br /> ....................................................................................................... ........ . .....Z. n....... ntt6' N m N + 0 SN <br /> T <br /> Inspection Date ....................................... v, m <br /> oin. dmor . . . <br /> 8 88 8 8 (a <br /> NOTE: A preliminary site inspection must be made and to proval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a opy 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 />